PUBLICACIONES
EN REVISTAS CIENTIFICAS DE CIRUGIA ESTETICA Y
PLASTICA
CIRUGIA ESTETICA DE LA MAMA.
MAMOPLASTIA DE AUMENTO
COSMETIC
Augmentation Mammaplasty with Anatomic Soft,
Cohesive Silicone Implant Using the
Transaxillary Approach at a Subfascial Level with
Endoscopic Assistance
Jose Mari´a Serra-Renom, M.D., Ph.D., Manuel
Ferna´ndez Garrido, M.D., and TaiSik Yoon,
M.D. Barcelona, Spain.
Background: Many augmentation
mammaplasty techniques have been developed paying
special attention to incision location and pocket
plane to achieve more naturallooking
breasts.
Methods: The authors’ technique
of choice in patients with mammary hypoplasia,
empty
breasts following a diet program, or more than
one lactation episode causing skin flaccidity
without ptosis is the placement of an anatomical
implant using a transaxillary approach in a subfascial
plane with endoscopic assistance. Thus, ideal
patients are those presenting
mammary hypoplasia, empty breasts following two
or more lactation episodes, and breast skin flaccidity
without ptosis, with the nipple-areola complex
placed above the inframammary fold. The technique
and its indications are presented thoroughly.
Results: Forty-five patients
were operated on using this technique from May
of 2001 to
October of 2003. One-year follow-up results showed
highly rated patient satisfaction. One
patient underwent an implant exchange because
of implant size dissatisfaction.
Conclusions: The authors prefer
subfascial plane implants to submuscular ones.
Possible
rotation of anatomic implants and the subsequent
asymmetry when contracting the pectoral muscle
are avoided. Pectoral muscle is not detached from
its insertions, resulting in less postoperative
pain. Likewise, the authors prefer a subfascial
to subglandular pocket since the weight of the
subglandular pocket and the glandular weight itself
are borne by the skin envelope leading to breast
ptosis development over time. On the other hand,
fascia provides additional support to the subfascial
implant, thus eliminating ptosis development and
achieving good filling of the upper pole similar
to the filling provided by subglandular implants.
(Plast. Reconstr. Surg. 116: 640, 2005.)
-From the Department of Plastic and Reconstructive
Surgery at University Clinic Hospital, University
of Barcelona Medical School, and Aesthetic
Surgery Institute Dr. Serra-Renom. Received for
publication March 3, 2004; revised November 23,
2004. DOI: 10.1097/01.prs.0000173558.52280.6e
-
When undertaking augmentation mammaplasty, we
prefer to use soft, cohesive, silicone
anatomical implants compared with the traditional
round implants1 since soft, cohesive, silicone
implants allow a wide spectrum of options with
regard to shape, height, width, and
projection to achieve appropriate filling of the
lower pole and match the particular needs of
each individual. We prefer the transaxillary approach
because it provides direct access to the subglandular,
subfascial, and submuscular planes, resulting
in the most inconspicuous
postoperative scar and integrity of the breast
tissue.2,3
The aesthetic result achieved by placing the implant
in the subglandular plane is satisfacperiod. Because
the skin bears the weight of the implant and the
gland itself, ptosis develops over time, especially
if skin flaccidity is present. By placing the
implant in a subfascial plane, the firm fascia
of the pectoralis major muscle provides additional
support to the skin helping to bear the weight
of the prosthesis and avoiding the development
of ptosis in the late postoperative period. Submuscular
implants may lead to implant malpositioning, implant
distortion during pectoralis muscle activity,
and significant postoperative pain, since the
muscle is detached from its insertions. An implant
in a subfascial plane benefits from additional
softtissue coverage of the implant and avoids
the drawbacks of submuscular location.
PATIENTS AND METHODS
Patients
The ideal candidate for this technique is a woman
with one of the following characteristics:
mammary hypoplasia; empty breasts after two or
more breast-feeding episodes with cutaneous flaccidity
in the absence of ptosis; or empty breasts after
a diet program with skin flaccidity in the absence
of ptosis, with the nipple-areola complex above
the inframammary fold from the lateral view.
Methods
Our technique is described below. First, an incision
is made at approximately 4 to 5 cm below the axillary
fold, from the anterior axillary line, but never
crossing beyond the lateral edge of the pectoralis
major muscle.
Once the skin incision is made, the superficial
fascia of the pectoralis major muscle is identified
and an incision is made parallel to the fibers
along the edge of the muscle.
Subfascial dissection is performed under the fascia
of the pectoralis major muscle and above the muscular
fibers with the aid of an endoscopic swivel retractor,
which we designed.9 When the most distal margin
is reached, the fascia is incised horizontally
at the level of the sixth rib and subcutaneous-subglandular
dissection is carried on downward to the new location
of the inframammary fold.
A saline-filled measuring implant is placed to
determine appropriate anatomical implant volume
and size, as well as to assess bilateral symmetry.
The measuring-implant is removed and hemostasis
is reviewed thoroughly by endoscopy.
The reference points for the prosthesis are plotted
on the skin with the aid of a pattern
taken from the prosthesis. The anatomical implant
is placed using two specially designed
retractors to allow simultaneous separation of
the pectoralis major and serratus muscles. The
reference points are assessed under endoscopic
view to ensure correct placement of the prosthesis.
Aspirative drainage is placed and the axillary
incision is closed. A dressing is carefully placed
to maintain the implant in the appropriate position
during the first week to avoid rotation due to
any involuntary movement of the patient.
Thereafter the patient should sleep in a supine
decubitus position with a brassiere to
maintain the position of the implant (Fig. 1).
RESULTS
From May of 2001 to October of 2003, we have operated
on 45 patients using this technique resulting
in uneventful postoperative recovery without any
discomfort. The patients’ ages varied from
22 to 48 years (mean, 33 years). No patient with
breast ptosis underwent this technique, although
patients with skin flaccidity were operated on.
In all cases, the nipple- areola complex was placed
above the inframammary fold from the lateral view.
The sizes of the implants (McGhan medium heightmedium
projection and medium height-full projection)
varied from 260 cc to 360 cc; the most frequently
used implants ranged between 280 cc to 320 cc.
Neither rotation nor prosthesis displacement has
been observed. Uppermammary- pole fullness has
been adequate with anatomical implants. In very
thin patients having a “pinch test”
result (a measurement of the thickness of the
skin and the subcutaneous tissue when pinched
between two fingers) of less than 1 cm, the upper
edge of the prosthesis was slightly conspicuous.
Axillary scars have evolved very satisfactorily
with no case of hypertrophy or intercostobrachial
nerve injury.
Preoperative and one-year postoperative views
of two patients are shown in Figures 2 and 3.
Patients were reviewed one day postoperatively,
after a week, a month, and 3 months,
and at the end of the first postoperative year.
The following items were assessed thoroughly:
symmetry; appropriate placement of the implants
with or without rotation; the height of the implant;
and the presence of capsular contracture (Fig.
3).
The results were very satisfactory with regard
to the volume and the final shape of the breast.
In only four patients with a “pinch test”
result of less than 1 cm was the upper edge of
the prosthesis slightly conspicuous. No capsular
contracture, wrinkling or rippling was found during
the follow-up appointment. Patient satisfaction
was assessed using a 0 to 5 scoring system to
indicate the patient’s satisfaction with
the final outcome, and using a 0 to 10 scoring
system to indicate satisfaction with volume, symmetry,
and breast separation or gathering.
The implant was replaced in one patient who considered
the implant to be too big.
During the first review, all patients were satisfied
with the shape but 90 percent thought
the implants were too big. In the one-month review,
40 percent of patients still thought the
implants were big although they liked the shape.
In the 3-month review, all patients were
satisfied with the shape and the size but one.
In that patient, the McGhan medium heightmedium
projection 320-cc implant was replaced by a McGhan
medium height-medium projection 260- cc implant.
Paradoxically, at the end of the first postoperative
year, 15 percent of the patients were still satisfied
with the shape of the breasts but would have chosen
a bigger implant.
These patients were told that according to their
thoracic diameter, the size of the implants was
suitable. They remained satisfied.
DISCUSSION
Our experience with the transaxillary approach
to placement of anatomical implants in a submuscular
plane is very satisfactory. Over four years, we
have operated on 160 patients with mammary hypoplasia.
Nine patients were reoperated on because unilateral
rotation of the prosthesis caused unsuitable breast
shape according to the anatomical shape of the
implant. Within the first 2 weeks of the postoperative
period, three patients experienced rotation due
to the development of a small hematoma.
Unfavorable breast shape developed in 35 cases
when patients contracted the pectoralis
muscles by pressing their palms together with
the elbows in an abducted and flexed position.
Twelve patients presented with hematoma during
the immediate postoperative period. Three required
reoperation to remove the hematoma with implant
reinsertion. In all cases, the pain and discomfort
during the immediate postoperative period were
noticeable. The endoscopic retractor designed
by the senior author9 (Snowden Pencer, Serra-Renom
Endoscopic Swivel Retractor System p(88-5140))
was utilized in all cases.
During the same period, 18 patients presenting
with skin flaccidity without ptosis underwent
transaxillary subglandular placement of anatomical
implants. All these patients presented
with a nipple-areola complex located above the
inframammary fold in the lateral view.
Fourteen patients developed empty breasts after
one or two breast-feeding episodes; four patients
developed empty breasts after following a diet
program. In these cases, we achieved good filling
and fullness of the pocket by placing the prosthesis
behind the gland, which is technically easier.
There is, however, the inconvenience of ptosis
due to the weight of the gland and the weight
of the implant being borne totally by the skin,
since
subglandular dissection splits up the support
ligaments between the deep layer of the superficialis
fascia and the pectoralis fascia.
The Cooper ligaments constitute a dense conjunctive
tissue coming from the overlying
skin into the breast, passing through the glandular
tissue, and reaching the superficialis fascia,
which covers the anterior and posterior glands
and provides subjection and conical
shape. Similarly, there are fibers joining this
deep layer of the superficialis fascia to the
superficial layer of the pectoralis major muscle
fascia. Placing the implant in a subglandular
plane provides satisfactory outcomes immediately
postoperatively but the weight that the
skin is bearing increases, and ptosis develops
over time.
Subfascial placement of anatomical implants provides
a proper filling of the cutaneous
pocket and the upper pole and corrects skin flaccidity,
which is achieved because the implant is placed
behind the gland. The immediate postoperative
recovery is better, with less pain and discomfort.5,6
Likewise, physical activity, including pectoralis
muscle contractions do not jeopardize implant
position because it is at a subfascial plane.7,8
The incidence of breast ptosis does not increase
after the first postoperative year with subfascial
implants because the fascia, in part, bears the
weight of the implant and the mammary gland. Similarly,
the incidence of ptosis does not increase because
fibrous attachments between the deep layer of
the fascia superficialis and the pectoralis muscle
fascia are preserved. The section of the fascia
at the sixth rib level allows better projection
of the lower gland pole. With this technique,
implant malpositioning (rotation) due
to muscular contraction is avoided.2,7
When patients with cutaneous flaccidity but no
ptosis from the lateral view are treated incorrectly
using a mastopexy with or without prosthesis,
the nipple-areola complex is located at a very
high position, causing a conspicuous scar, which
is irreversible. We believe that an anatomical
breast implant placement in a subfascial plane
utilizing the transaxillary approach combines
the advantages of the subglandular and submuscular
planes and avoids their disadvantages. Technically,
the transaxillary approach for the subfascial
implant is more complicated than subglandular
or submuscular placement, but with the aid of
the swivel retractor for the pectoralis major
and serratus muscles and the endoscopic view,
the difficulty decreases greatly.
When using soft, cohesive, silicone gel anatomical
implant, the transaxillary insertion becomes easier
because the implant is softer. The transaxillary
approach is performed by dissecting a pocket with
endoscopic assistance and using a measuring implant
to assess the accurate size of the implants required
as well as the symmetry between the two pockets
before placement of the definitive prosthesis.
The postoperative dressing is very important to
avoid rotation of the implant. The patient should
sleep in a supine decubitus position for one month.
In patients with empty, flaccid breasts, as often
occurs after one or more lactation episodes, the
technique of choice in our institute is the subfascial
placement of soft, cohesive, silicone gel anatomical
implants through the transaxillary approach with
endoscopic assistance
Jose Mari´a Serra-Renom, M.D., Ph.D.
Aesthetic
Surgery Institute Dr. Serra-Renom
Virgen
de la Salud 78-5° E
Cli´nica
Quiro´n
Barcelona,
Spain
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