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 5. CONSENTS AND INSTRUCTIONS

 

     Included in this workshop are informed consents, instructions, and guidelines for after-care in the information booklet for patients entitled, "Information About An Improved Appearance" and the augmentation mammoplasty information sheet. These may be helpful to your patients, and may be used by workshop participants.

 

6. SURGICAL METHODS

 

In this workshop you will meet faculty members and others who have performed thousands of breast implant operations. They are proponents of many different surgical methods (all with various valid merits), and all have the same purpose of providing the most desirable, trouble free, and pleasing results for their patients.

These different methods can be divided into the four different incision sites:

          1. Inframammary

           2. Areolar 

           3. Axillary

           4. Umbilical

  There are two breast implant location sites:

          1. Subglandular 

           2. Subpectoral  

And there are the two types of saline implants possible:

          1. Smooth

          2. Textured

 

The total is 4 x 2 x 2 = 16 different operations. During the 1998 meeting, Mark Leventhal performed an umbilical under-the-muscle technique. Paul Blumberg has made a beautiful videotape of that technique.

Also, there are variations as to instruments, antibiotics, steroids, and types of implants used. There are many different valid opinions, and each surgeon will decide for himself what is best for his patients. While it is not possible to discuss all the pros and cons and the many ideas, opinions and the reasons behind all of these approaches, it is appropriate to point out a few of the  most widely accepted facts and opinions.

 

 A. Inframammary

 

Traditionally the most widely used incision has been the inframammary. It is safely and easily performed. The incision can  be enlarged as much as necessary, and there is direct access to the area of dissection, which can be above or below the pectoral  muscles, with primarily blunt dissection being performed. Hemostasis is easily achieved with good exposure.

Offering the greatest ease and exposure, this is probably the safest approach. Care of complications such as drainage of hematoma or open capsulotomy are also accomplished most easily with this approach.

The problem with the inframammary approach is the resultant scarring.  The scar in this location is more visible than with the areola or axillary approaches, and this is the main drawback of using this incision, except in the Grade II or III pendulous breasts, when skin is touching skin and the incision site will be hidden.

The indication for an inframammary incision therefore should best be limited to:

1. Breast skin overlying chest skin (Grade III pendulous breasts), so that the incision area will not be visible (even in the supine position) after lowering the inframammary crease. Even so, the incision is tucked up under the breast, about 1 cm above the new IM crease (not in the crease itself) and never on the chest wall.

2. A candidate who has had previous scars on the breast, chest or abdomen (such as with C section) heal very well without hypertrophy or keloid formation.

3. Very light-skinned patients. Scars de-pigment and will show less and have a reduced incidence of keloid in very light-skinned persons.

4. Implants requiring a short incision (i.e. saline implants which usually require 3 cm or less for an incision).

5. A candidate with a previous inframammary scar. Why put one somewhere else?

 

B. Areola

 

The areola incision is often called peri-areolar, meaning around the areola, and I call it areola to remind the reader that it is in the brown skin of the areola itself and not in the white skin around the areola, and it is also not at the junction of the brown and the white skin (areolar border).

The peri-areolar skin (or skin at the junction of the areola and surrounding breast skin) heals far more poorly, is much more likely to scar or be visible, and is more likely to form a keloid than the areola skin. The areola skin is like the lower eyelid. It does not scar and does not keloid. If the areola is brown or pink and the tiny white line of your serpentine areola incision shows at all you can put tattoo pigment into it and match the skin color of the areola, making it invisible in about 5 minutes with only a syringe and needle and no other equipment required, just the pigment.

Our eyes normally follow a straight line more easily than a very curved line, and if we place the areola incision in the wrinkled brown area where the pigmented skin heals very well and hide the incision in the tortuous curves of a wrinkle, we have an excellent chance of an invisible, or at least an unnoticeable scar.

Also, any whiteness that results from a scar in this area can be covered with tattoo pigment to match the areola. This incision is very direct and allows good visibility of the area of dissection, but is limited in size, and may be difficult for some to work through if they are not accustomed to using a headlight while working with monocular vision. It helps to use a suction cautery for hemostasis, rather than the usual bipolar or monopolar forceps or electrode.

When there are more than two or three revisions required for some reason on one side, the small areola can become distorted if the scar is excised each time. Also it is more difficult to get the implants in through tiny areolar incisions of less than 2 cm in length. When they are in, it is even more difficult to get them out. In any patient who is a likely keloid former, the area of the areola is probably the worst area for a keloid to develop as it causes the greatest deformity, more so than the other incision sites. Personally I have not had any problems, but I have seen photographs of one problematic case that was peri-areolar from Tom Stephenson's collection. In my experience with 500+ areolar incisions, there have been no keloids.

 

 C. Axillary

 

The axillary incision is further removed from the area of dissection, and may provide the least noticeable scar. Hemostasis could be a bit more difficult to obtain theoretically but in my experience, in about 4 out of 5 cases (especially under the muscle) the cautery is not required at all. This is achieved with a large volume of local anesthetic and blunt dissection.

At first there can be more difficulty in accurately determining the breast shape and the position and symmetry of the newly created inframammary fold. But after doing this procedure a few times there is no problem in estimation, and one can get as good or better shape results as with any other procedure.

With the axillary approach it is easier to control the inframmary fold shape and position than with the other three incisions. This is because you are using blunt large dissectors that allow the pushing down and out of the inframammary fold as is often needed.

Whenever capsules develop, it may be a little bit more difficult to perform open capsulotomy.  There are also the nerves and vessels of the axillae to be knowledgeable about and to be careful not to damage. 

It also may at first seem more difficult to me to correct asymmetries, such as of the position of the inframammary folds, and to accurately place the implants in pendulous breasts with this approach. But actually it is not. It is easier to lower the inframammary fold for a Grade III pendulous breast with the axillary approach than with any other.

The nerves and the vessels in the axillae are subject to injury in the axillary approach, and numbness from injury to the intercostobrachial nerves to the axilla and under the surface of the upper arm is quite common, though fortunately usually temporary. The intercostobrachial is a subcutaneous branch of the 2nd intercostal nerve that crosses subcutaneously from the chest through the axilla as it goes to supply sensation to the under arm, especially over the area of the size of a half dollar or silver dollar.

An excellent indication for the axillary incision is the patient with very small, light, unwrinkled areola who wants the least visible scar. This might be the younger, nulliparous patient.

Shorter patients are a little easier to do with the axillary approach than very tall persons because of the distance from the axilla to the inframammary fold. 

Less muscular patients are also easier to work on when the implant is placed below the pectoral major, because in the axillary approach the muscle is lifted to insert the implant and have access to the pocket.

This is not a major problem, however, and the position of the arm in this approach is very important, so that the muscle is relaxed. The higher the elbow is positioned, the more relaxed the muscle. This approach (like the inframammary) does not violate or transgress through breast tissue or breast ducts, and the areola incision, to a certain extent, usually does.

After thorough discussion of the options for incision sites with each patient and allowing them to consider an incision site that the surgeon would also find to be optimal, the incision site is chosen. The surgeon's recommendation can easily sway the patient (in most instances) to the site he prefers. In the workshop, you will find members of the faculty who prefer each of the different sites, and each of the sites will be demonstrated on videotapes and in surgery. Enclosed in the workbook are photographs with captions explaining the routine steps of the areola approach.

Also included is the list of instruments used and a photograph of the instruments and back table. Actually, the one large paddle shaped breast dissector, the Dingman, is only set out for axillary dissections, and is wrapped separately.

The other long dissector shaped like a urethral sound with a handle on one end is used as a blunt dissector in all approaches.   For any of the three approaches, most surgeons either use a headlight or a fiber-optic, lighted, long retractor to be able to see the dissected area and obtain hemostasis. I personally rely on a headlight and do not have a fiber-optic retractor. If I were doing all the axillaries above the muscle, there would be more bleeding and I would probably get a fiber-optic retractor.

But with the subpectoral axillary procedure I cannot remember having any problem with hemostasis and usually do not inspect the dissection area if there is no bleeding. There is usually no bleeding in more than 4 out of 5 cases. Most of the procedures I do are axillary subpectoral.

One of the problems with the axillary approach is that while I have done a blunt sort of capsulotomy, and you might do a fairly nice capsulotomy with an endoscopic technique, I have not seen or heard of a thorough capsulectomy through the axilla. Not to say it is impossible. Maybe you could climb Everest barefoot. It would be difficult and treacherous. And a capsulectomy is going to be needed with a dense capsule that is to be replaced with a new textured implant that needs a completely new interface.

So the axillary patient needs to understand that she may also require another incision somewhere else, either for this operation or at a later date to fix a problem that cannot be repaired through the axilla.

 

7. SUBPECTORAL, SUBFASCIAL VS. SUBGLANDULAR

 

Originally when augmentations were first performed in the early 1960s with silicone breast implants, they were placed in the subglandular position over the pectoral muscle.

They were hard. They were hard to begin with. If you look at the old Dow-Corning product descriptions of the implants, there were no soft implants in the early sixties. They were teardrop shaped, often with Dacron patches on the back, and they all became hard (and were quite firm before they were implanted).

Since the early type of implants were firm to begin with, they were expected to be firm, and capsule contracture was not felt to be a major problem.

This may be one of the secrets of the Meme implant, that is that they are firm to begin with, and therefore do not contract into a ball so easily like the softer implants do. In those early days firmness was thought to be desirable to a certain extent anyway.

 Then in a few years, in the late sixties, the patients were asking if something couldn't be done about the hardness, and softer implants were soon on the market. Then in 1967, C.O. Griffiths first reported the submuscular implant in augmentation.

As the capsular contracture problem became more common with the softer implants, more surgeons shifted to the submuscular technique, until in the 1980s  there were many articles and opinions in the literature that the implants tend to remain softer in the submuscular position. The advantages of the subpectoral position are:

 

1. Dissection is just as easy as prepectoral.         

2. Bleeding is no greater.         

3. Hemostasis is as easily obtained.         

4. It is substantiated in the literature.         

5. It is about as popular as prepectoral if not more.        

6. The muscle over the implant reduces the feel of hardness if contractures occur.

7. The muscle movement presses on the implants and may thus keep them a little softer.

8. The muscle over the implants provides a smoother straighter contour from clavicle to nipple without a demarcation line, especially with capsule  contracture - no “stuck-on” look.

9. The muscle force pushes the implants down, counteracting the  tendency of the capsule contracture  to push the implants superiorly.        

10. The implants are further removed from breast tissue with less chance of being          involved in breast  diseases, lactation, or breast biopsy.      

11. There may be less numbness of the nipples due to less damage to the third, fourth, and fifth intercostal nerves.

12. It is said to be better for mammography to be below the muscle.

 

The main disadvantages of submuscular implants are:

 

1. Anesthesia, especially local, is more difficult to achieve.           

2. Post operative pain may be greater.           

3. The muscle may be weakened.           

4. The muscle force may push the implant down too far.            

5. There appears to be less cleavage, but this is debatable.           

6. Patients can have a flatter appearance with less projection of the breasts forward.

7. The muscles may be visible over the implants when contracted, and press the implants laterally. This can usually be prevented. It occurs more frequently with an areolar incision.

8. The breasts may not feel as soft or move as freely.           

9. If capsule contracture occurs, closed capsulotomy is more difficult.

 

With all these different debatable considerations, one can see that there is no definite best way for all patients. Each patient's special circumstances may determine which implant position is best for her.

For example, if the patient is very slender with very little subcutaneous or breast tissue covering the upper chest, the patient is a good candidate for submuscular implants, because if capsule contracture occurs and the amount of tissue covering the breasts is exceedingly thin, the implant becomes more noticeable. A sharp demarcation line may occur at the superior margin of a spherical contracture, causing a stuck-on, coffee cup like appearance that the submuscular position can partly prevent.

If, however, the patient has considerable subcutaneous tissue and breast tissue to cover the implant, and is particularly desirous of cleavage, the submammary position might be better. For the patient who is a professional or serious amateur athlete who uses her arms, such as with bowling, golf, tennis, swimming, etc., thorough counseling is needed to choose the best approach. 

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Program 2013  l Program 2014  Program 2015 | Program 2016 | Program 2017 | Program 2018

The American Society of Cosmetic Breast Surgery 2017    Last modified: June 23, 2017