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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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