Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

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Chapter 2 Breast Augmentation: Subglandular, Subfascial, and Submuscular Implant Placement

Table 1 Breast Local Anesthetic Formula Drug

Amount  25 mL  25 mL  25 mL  25 mL 100 mL

½% lidocaine plain

½% lidocaine/1:200 000 epinephrine ½% bupivacaine/1:200 000 epinephrine

Injectable saline

Total concentration : ¼% lidocaine, 1/8% bupivacaine, 1:400 000 epinephrine

FIG 13 • Breast infusion with 20-cc syringe and a 22-gauge spinal needle.

T E C H N I Q U E S

■■ Subglandular and Subfascial Placement ■■ The distinction between the subglandular and the subfas- cial plane is subtle and opinions differ on whether it is of clinical importance. ■■ The common aspect is both involve dissection superficial to the muscle and avoid both, the animation deformity associ- ated with the muscle and the limitation the muscle plays on the ability of the implant to expand the breast envelope. Inframammary Fold Incision ■■ A variety of incisional approaches to the subglandular, subfascial, or submuscular pocket are possible, the infra- mammary fold (IMF) being the most common. ■■ This incision is performed the same for both subglan- dular or subfascial pockets. ■■ After determining the IMF position (either the native true fold position or the planned lowered position), a para- median line is drawn through the center of the breast and bisects the newly drawn IMF. ■■ The incision’s medial extent begins 1 cm medial to the paramedian line and extends laterally for the appropriate distance, as previously described based on the implant type ( TECH FIG 1A ). ■■ The incision is made with a no. 15 blade through the skin to the mid-dermis ( TECH FIG 1B ).

■■ Dissection is then carried out with electrocautery through the skin and subcutaneous tissue, beveling superiorly while rotating the breast off of the chest wall. ■■ Once dissection has been carried superiorly for 1 cm, the dissection is carried through the superficial fascia and toward the chest wall. ■■ The beveling preserves a small cuff of superficial fascia at the incision, which ensures the fold is not inadvertently lowered and also provides a cuff of Scarpa fascia that will prove useful during closure ( TECH FIG 1C ). ■■ As dissection proceeds toward the chest wall, a constant upward retraction of the breast tissue is maintained, exposing the pectoralis major with its overlying fascia ( TECH FIG 1D ). ■■ The upward retraction of the breast tissue is key, as the suspensory ligaments of the breast concomitantly elevate the muscle to expose the muscle edge. ■■ The only distinguishing characteristic is at the level of the IMF incision, dissection begins over the pectoralis fascia for the subglandular pocket or deep to the fascia for a subfascial pocket. ■■ The elevation of the subglandular pocket is superficial to the pectoralis fascia, and the elevation of the sub- fascial is deep to the breast and fascia, but superficial to the muscle.

TECH FIG 1  • A. Paramedian line drawn from the nipple to the IMF. Note the 5 cm incision length. B. 5-cm inframammary incision. C. Cuff of Scarpa fascia. D. Upward rotation of the breast with retractor exposes the underlying pectoralis muscle.