HISTORY

History Attempts at surgical breast augmentation were. – At first, autogenous tissue was utilized exclusively and Paraffin and silicone, respectively were injected directly into the breast, but these techniques proved to have unacceptable complications The implantation of Ivalon sponge was reported, but follow-up revealed poor results Cronin and Gerow presented a report on the use of silicone gel prostheses for cosmetic breast augmentation, effectively introducing modern breast augmentation Inflatable prostheses were introduced by Arion.

SURGICAL TECHNIQUE

Subglandular or Submuscular Subglandular - under the breast gland Submuscular position - beneath the pectoralis major muscle

Subglandular Main advantage: lowers the risk of SFCC – possibly by decreasing potential contamination via breast ducts, or by a “massaging” effect of the muscle itself. As soft tissue coverage of the implant is improved, the risk of visible implant rippling is also diminished Less painful in the postoperative period Preferred in patients who are avid body builders in whom highly developed pectoralis muscles may compromise implant projection/shape

Submuscular Subpectoral or Total Subpectoral – the implant is placed under the pectoralis major Total – involves implant coverage with the pectoralis major, the serratus anterior, and (if necessary) portions of the anterior rectus fascia. – Typically used in breast reconstruction after mastectomy when soft tissue coverage of the implant is lacking.

Access Incisions Inframammary – places an incision at the level of the inframammary fold, immediately lateral to the breast meridian. – offers excellent visualization – allows careful modification of the level of the inframammary fold, which is commonly lowered to accommodate the implant. – Any future revisions that may become necessary can generally be performed through the same access incision.

Access Incisions Periareolar – incision just within the borders of the areola – also offers excellent visualization and allows careful modification of the level of the inframammary fold – revisions can generally be performed through the same access incision – some sources cite an increased risk of diminished nipple sensibility and inability to lactate using this approach

Access Incisions Axillary – placement of the implant through the axilla – obviates the placement of a scar on the breast – visualization is poor in the distal (inferior) areas of the dissection, increasing the risk of postoperative inframammary fold asymmetry – revisions may be difficult, if not impossible to perform via the axilla, necessitating secondary scars on the breast – use of endoscopic technique improves visualization of the dissection pocket and may alleviate these concerns.

SURGICAL PROTOCOL

Principles in Augmentation Mammaplasty 1. First, a generous dissection of the implant pocket must be performed. 2. The inframammary fold is usually lowered to a level dictated by implant size, the level of the preexisting fold, and the desire to maintain symmetry. 3. As in any procedure, meticulous hemostasis and attention to sterile technique are important. 4. In the course of surgery, the patient is often placed in a seated position to assess size/symmetry prior to closure. 5. The use of disposable or reusable implant sizers is useful in selecting the appropriate implant size.