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AESTHETIC MAMMAPLASTIESPractical Atlas of Plastic Surgery

Giovanni Botti

with the contribution ofChiara Botti

Antonio CellaAlessandro Gualdi

Karin Moust

SEE® - FIRENZE

17Aesthetic Mammaplasties - Practical Atlas of Plastic Surgery

Contents

ContentsIntroduction ............................................................................................................................................................. 9Preface and purpose of the text .............................................................................................................................. 11Method of use ........................................................................................................................................................ 13Acknowledgements ............................................................................................................................................... 15

CHAPTER 1 – OUTLINE OF SURGICAL ANATOMY AND PATHOPHYSIOLOGY OF THE BREAST ....... 27Anatomy of the breast. Front view ........................................................................................................................ 28Anatomy of the breast. Side view .......................................................................................................................... 29General information ............................................................................................................................................... 30

The breast cleavage .......................................................................................................................................... 30Position and shape ............................................................................................................................................ 31Cooper’s ligaments ........................................................................................................................................... 31Areola and nipple ............................................................................................................................................. 32The mammary gland ......................................................................................................................................... 33The peri-glandular fasciae ................................................................................................................................ 34

Submammary muscular system ............................................................................................................................. 35Vascular supply ...................................................................................................................................................... 36

Arterial system.................................................................................................................................................. 36Venous system .................................................................................................................................................. 36Arterial vascularization of the breast ................................................................................................................ 37Lymphatic system ............................................................................................................................................. 38

Innervation ............................................................................................................................................................. 39The measurements ................................................................................................................................................. 40Ideal breast parameters .......................................................................................................................................... 41

Further assessment............................................................................................................................................ 42Further considerations ...................................................................................................................................... 43

CHAPTER 2 – AND NOW LET’S CHOOSE OUR CASE ....................................................................................... 45Augmentation .................................................................................................................................................. ......46

Totally submuscular implants ........................................................................................................................... 46Partially submuscular implants......................................................................................................................... 46Subglandular implants ...................................................................................................................................... 47

Augmentation with periareolar mastopexy ............................................................................................................ 48Implants with circumareolar skin excision ....................................................................................................... 48Implants with round block and parenchyma expansion ................................................................................... 48

Augmentation with vertical mastopexy ................................................................................................................. 49Simple mastopexy .................................................................................................................................................. 50Breast reduction ..................................................................................................................................................... 51Gynecomastia ........................................................................................................................................................ 52Inverted nipple ....................................................................................................................................................... 52Asymmetries .......................................................................................................................................................... 53

CHAPTER 3 – COMPLICATIONS ............................................................................................................................. 55Augmentation complications ................................................................................................................................. 56

Periprosthetic contracture ................................................................................................................................. 56Double bubble .................................................................................................................................................. 56Mondor’s syndrome (“string phlebitis”) ........................................................................................................ 56Implant rupture ................................................................................................................................................. 56Displaced gland .............................................................................................................................................. 57Breast swelling ............................................................................................................................................... 57Displaced implants ......................................................................................................................................... 58Extrusion......................................................................................................................................................... 58

18 Aesthetic Mammaplasties - Practical Atlas of Plastic Surgery

Contents

Folds ............................................................................................................................................................... 58Incorrect positioning plane ............................................................................................................................. 59

Augmentation and mastopexy complications ...................................................................................................... 59Inadequate surgical indications ...................................................................................................................... 59Symmastia (“fused” breast) ............................................................................................................................ 59Areolar necrosis .............................................................................................................................................. 59

Mastopexy and reduction complications ............................................................................................................. 60High areolas .................................................................................................................................................... 60Caudal dog ears .............................................................................................................................................. 60Secondary ptosis ............................................................................................................................................. 60Adipose necrosis ............................................................................................................................................. 60Scarring proplems ........................................................................................................................................... 61Secondary nipple ............................................................................................................................................ 61

CHAPTER 4 – BREAST AUGMENTATION ........................................................................................................... 65The implants ........................................................................................................................................................ 67

Their contents ................................................................................................................................................. 67The shape ............................................................................................................................................................. 69“Round” or “teardrop” implants .......................................................................................................................... 70

Round implants ............................................................................................................................................... 70Teardrop implants ........................................................................................................................................... 70Teardrop implants: commercial myth or actual evolution? ............................................................................ 71Huge implants? No thanks! ............................................................................................................................ 72

The size ................................................................................................................................................................ 73How to calculate it .......................................................................................................................................... 73How to choose it ............................................................................................................................................. 73

The envelope ........................................................................................................................................................ 74Incision site .......................................................................................................................................................... 75

Inframammary fold ......................................................................................................................................... 76Areola ............................................................................................................................................................ 76Axilla .............................................................................................................................................................. 77Navel............................................................................................................................................................... 78

The lodging plane ................................................................................................................................................ 78Subcutaneous positioning ............................................................................................................................... 78Subglandular positioning ................................................................................................................................ 78Subfascial positioning .................................................................................................................................... 79Partial submuscular positioning ..................................................................................................................... 79Total submuscular positioning ........................................................................................................................ 79Dual plane ....................................................................................................................................................... 79

Recovery .............................................................................................................................................................. 81Scars ..................................................................................................................................................................... 82Mammary implants and safety ............................................................................................................................ 83In practise: how, what, how much, where...and then? ......................................................................................... 84Common issue (from A to Z) ............................................................................................................................... 87

Accolate .......................................................................................................................................................... 87Betadine .......................................................................................................................................................... 87Compression ................................................................................................................................................... 87Glandular expansion in augmentation surgery ............................................................................................... 87Drainage ......................................................................................................................................................... 88Dynamic implant dislocation .......................................................................................................................... 89Hemiperiareolar incision ................................................................................................................................ 90Gloves ............................................................................................................................................................. 90Lubricants ....................................................................................................................................................... 91Massage .......................................................................................................................................................... 91The patient’s position during the operation .................................................................................................... 91


Contents

Radiowaves in the submuscular dissection?................................................................................................... 92Texturization ................................................................................................................................................... 94Transsexuals ................................................................................................................................................... 95

CHAPTER 5 – THE RELATIONSHIP WITH THE PATIENT IN BREAST AUGMENTATION SURGERY . 99The preoperative examination ............................................................................................................................. 101

Necessary materials ........................................................................................................................................ 101The consultation ............................................................................................................................................ 101Anatomy, incision and position of the implants ............................................................................................. 102Anaesthesia ..................................................................................................................................................... 103Volume and type of implants .......................................................................................................................... 103The operation in short ..................................................................................................................................... 104Possible complications ................................................................................................................................... 105

Answers to questions frequently asked by patients ............................................................................................. 106Examining the forms to be handed to the patient .................................................................................................111

Pending surgery .............................................................................................................................................. 112Request for tests to the family doctor ............................................................................................................. 112Short informed consent form for the operation .............................................................................................. 113Post surgery instruction .................................................................................................................................. 114Post operative massage ................................................................................................................................... 115

CHAPTER 6 – BREAST AUGMENTATION: ILLUSTRATED SURGICAL TECHNIQUES ........................... 117Instruments and materials .................................................................................................................................... 118Special precautions for lodging teardrop implants .............................................................................................. 119Totally submuscular augmentation ...................................................................................................................... 121

Advantages ..................................................................................................................................................... 121Disadvantages ................................................................................................................................................. 121Key points ....................................................................................................................................................... 126The preoperative markings ............................................................................................................................. 127Surgical technique .......................................................................................................................................... 128The result ........................................................................................................................................................ 137

Partially submuscular augmentation .................................................................................................................... 139Advantages ..................................................................................................................................................... 139Disadvantages ................................................................................................................................................. 139Key points ....................................................................................................................................................... 144The preoperative markings ............................................................................................................................. 145Surgical technique .......................................................................................................................................... 146The result ........................................................................................................................................................ 153

Dual plane augmentation ..................................................................................................................................... 155Surgical technique .......................................................................................................................................... 156

Subglandular augmentation ................................................................................................................................. 159Advantages ..................................................................................................................................................... 159Disadvantages ................................................................................................................................................. 159Key points ....................................................................................................................................................... 164The preoperative markings ............................................................................................................................. 165Surgical technique .......................................................................................................................................... 166The result ........................................................................................................................................................ 171

CHAPTER 7 – AUGMENTATION COMPLICATIONS ........................................................................................ 173Capsular contracture ............................................................................................................................................ 175

Classification, causes and prevention ............................................................................................................. 176Treatment ........................................................................................................................................................ 179 Recent contracture .................................................................................................................................... 179 Severe and/or established contracture ...................................................................................................... 179


Capsulotomy ............................................................................................................................................. 180 Capsulectomy ........................................................................................................................................... 182Implant removal with total capsulectomy ...................................................................................................... 185Implant removal with total capsulectomy and mastopexy ............................................................................. 188Two-step implant and capsule removal .......................................................................................................... 193

Double bubble ...................................................................................................................................................... 194Prevention ....................................................................................................................................................... 194Treatment ........................................................................................................................................................ 195Breast expantsion for double bubble correction ............................................................................................. 197

The Mondor’s syndrome...................................................................................................................................... 200Implant rupture .................................................................................................................................................... 201

Prevention ....................................................................................................................................................... 201Diagnosis ........................................................................................................................................................ 202Treatment ........................................................................................................................................................ 202

Gland displacement ............................................................................................................................................. 205Small-haematoma or undetected seroma ....................................................................................................... 205Submuscular implants with glandular ptosis (primary or secondary) ............................................................ 206

Mammary swelling .............................................................................................................................................. 208Infections ........................................................................................................................................................ 208Haematomas ................................................................................................................................................... 212Seromas .......................................................................................................................................................... 214Implant volume increase................................................................................................................................. 216

Implant displacement ........................................................................................................................................... 218Non-surgical repositioning ............................................................................................................................. 218Surgical repositioning ..................................................................................................................................... 218 Capsulectomy-capsulorrhaphy to correct a displacement ........................................................................ 226

Skin folding ......................................................................................................................................................... 228Causes and prevention .................................................................................................................................... 228Treatment ........................................................................................................................................................ 228 Correction by fat grafting ......................................................................................................................... 230

Wrong plane ......................................................................................................................................................... 231Sensitivity reduction ............................................................................................................................................ 233Visible scars ......................................................................................................................................................... 233

CHAPTER 8 – AUGMENTATION MAMMAPLASTY TECHNIQUE UPDATE................................................ 235Our relationship with the patient ......................................................................................................................... 237How implants should be chosen .......................................................................................................................... 237The choice of the technique ................................................................................................................................. 237Technical details .................................................................................................................................................. 238

How to choose anatomical implants ............................................................................................................... 238From the beginning......................................................................................................................................... 238

The bra cup .......................................................................................................................................................... 239Surgical planning and important details using anatomical implants ................................................................... 247Computer-based implant choice (Stan method) .................................................................................................. 251410 style teardrop implants .................................................................................................................................. 255

Submuscular treardrop implants ..................................................................................................................... 255Breast augmentation with 410 style teardrop implants (dual plane) .............................................................. 260

510 style teardrop implants .................................................................................................................................. 265Breast augmentation with 510 style teardrop implants .................................................................................. 270

The devil’s advocate ............................................................................................................................................ 274Why teardrop implants are better than round ones ......................................................................................... 274Why round implants are better than anatomical ones .................................................................................... 275

Personal remarks on the real or alleged progress of the past few years .............................................................. 276

Contents


CHAPTER 9 – BICOMPARTMENTAL BREAST LIPOSTRUCTURING .......................................................... 279Purpose ................................................................................................................................................................ 281Materials and methods ......................................................................................................................................... 282

Patients ........................................................................................................................................................... 282Instruments ..................................................................................................................................................... 282

Technique ............................................................................................................................................................. 282External breast skin expansion ....................................................................................................................... 282Surgical planning ............................................................................................................................................ 283Body-contouring set-up .................................................................................................................................. 284Fat harvesting ................................................................................................................................................. 284Fat preparation ................................................................................................................................................ 284Breast set-up ................................................................................................................................................... 284Fat transplantation .......................................................................................................................................... 284Manual reshaping ........................................................................................................................................... 285

Results ................................................................................................................................................................. 285Conclusions ......................................................................................................................................................... 289Surgical technique ............................................................................................................................................... 299

CHAPTER 10 – MASTOPEXY AND BREAST REDUCTION: GENERAL INFORMATION ......................... 303Ptosis and hypertrophy ........................................................................................................................................ 305Technical problems common to ptosis and hypertrophiy .................................................................................... 306

Areolar pedicle flap marking and scar extension ........................................................................................... 306Mantaining valid vascularization of the nipple-areola complex .................................................................... 306 Length of the areolar flap ......................................................................................................................... 306 Areolar flap marking................................................................................................................................. 307 Venous drainage ........................................................................................................................................ 307Scars ............................................................................................................................................................... 308

Further technical details common to mastopexy and reduction .......................................................................... 311More on markings and scars ........................................................................................................................... 311

Hall-Findlay supero-medial pedicle .................................................................................................................... 315

CHAPTER 11 – THE RELATIONSHIP WITH MASTOPEXY AND BREAST REDUCTION PATIENTS ..... 317Mastopexy ........................................................................................................................................................... 319

The consultation ............................................................................................................................................. 319Technical information ..................................................................................................................................... 319The operation in short ..................................................................................................................................... 321Possible complications .................................................................................................................................. 321Operation fee .................................................................................................................................................. 321

Breast reduction surgery ...................................................................................................................................... 322Request for tests to the family doctor ............................................................................................................. 323Short informed consent form for the operation .............................................................................................. 324Post surgery instruction .................................................................................................................................. 326

CHAPTER 12 – PTOSIS IN HYPO AND NORMOTROPHIC BREASTS ........................................................... 327Ptosis .................................................................................................................................................................... 329

Classification .................................................................................................................................................. 329Skin ................................................................................................................................................................. 330Fat ................................................................................................................................................................... 332Glands ............................................................................................................................................................. 332Cooper’s ligaments ......................................................................................................................................... 332Adhesion of the breast to the muscular aponeurosis ...................................................................................... 332

Clinical exam of the ptotic breast ........................................................................................................................ 333

Contents


Mastopexy with or without implants .............................................................................................................. 334Correction of ptosis and scars: a dilemma not always easy to solve ................................................................... 334

Which mastopexy? A brief guide to choose the best technique ..................................................................... 335

CHAPTER 13 – MASTOPEXY WITH BREAST AUGMENTATION .................................................................. 337Periareolar mastopexy ......................................................................................................................................... 339

Advantages and criticisms .............................................................................................................................. 339Gland plication ............................................................................................................................................... 341How to close the purse string ......................................................................................................................... 343

Periareolar mastopexy with breast augmentation without expansion ................................................................. 345Advantages ..................................................................................................................................................... 345Disadvantages ................................................................................................................................................. 345Key points ....................................................................................................................................................... 350The preoperative markings ............................................................................................................................. 351Surgical technique .......................................................................................................................................... 352The result ........................................................................................................................................................ 358

More details on submuscular dissection in periareolar mastopexy without implants ......................................... 359Periareolar mastopexy with glandular expansion and implants .......................................................................... 361

Advantages ..................................................................................................................................................... 361Disadvantages ................................................................................................................................................. 361Tubular and tuberous breast ........................................................................................................................... 362Key points ....................................................................................................................................................... 370The preoperative markings ............................................................................................................................. 371Surgical technique .......................................................................................................................................... 372The result ........................................................................................................................................................ 379

Breast augmentation with vertical mastopexy ..................................................................................................... 381Advantages ..................................................................................................................................................... 381Disadvantages ................................................................................................................................................. 381Augmentation with vertical mastopexy .......................................................................................................... 383Key points ....................................................................................................................................................... 390The preoperative markings ............................................................................................................................. 391Surgical technique .......................................................................................................................................... 392

CHAPTER 14 – VERTICAL MASTOPEXY ............................................................................................................ 401Further considerations on mastopexy techniques ................................................................................................ 402Traditional vertical mastopexy ............................................................................................................................ 405


Vertical mastopexy with autoprosthesis .............................................................................................................. 421Advantages ..................................................................................................................................................... 421Disadvantages ................................................................................................................................................. 421Key points ....................................................................................................................................................... 426Important details ............................................................................................................................................. 426The preoperative markings ............................................................................................................................. 428Surgical technique .......................................................................................................................................... 430The result ........................................................................................................................................................ 437Graf’s autoprosthesis fixation......................................................................................................................... 438Superior pedicle autoprosthesis ...................................................................................................................... 441

Contents


CHAPTER 15 – BREAST REDUCTION SURGERY ............................................................................................. 443Cosmetic and functional implications ................................................................................................................. 444

Mammary hypertrophy: the aesthetic point of view ....................................................................................... 444Mammary hypertrophy: the functional point of view .................................................................................... 444

Sequential surgical approach to mammary hypertrophy ..................................................................................... 446Universal technique? No, thanks .................................................................................................................... 447

Breast reduction with vertical scar and superior pedicle (Lassus-Lejour) .......................................................... 449Advantages ..................................................................................................................................................... 449Disadvantages ................................................................................................................................................. 449Key points ....................................................................................................................................................... 453The preoperative markings ............................................................................................................................. 454Surgical technique .......................................................................................................................................... 456The result ........................................................................................................................................................ 464

Inverted T scar breast reduction: the preoperative markings ............................................................................... 467Upper pedicle reduction with inverted T scar ...................................................................................................... 471


Inferior pedicle breast reduction .......................................................................................................................... 483Surgical technique .......................................................................................................................................... 486

Liposuction-assisted breast reduction .................................................................................................................. 488Postero-infero-superior pedicle breast reduction (Mc Kissock Technique) ........................................................ 491


Breast reduction with nipple-areola complex grafting (Thorek technique) ........................................................ 505Why do we still use breast reduction with nac grafting? ..................................................................................... 506

Technical details ............................................................................................................................................. 506Graft ................................................................................................................................................................ 507Key points ....................................................................................................................................................... 512The preoperative markings ............................................................................................................................. 513Surgical technique .......................................................................................................................................... 514

CHAPTER 16 – GYNECOMASTIA ......................................................................................................................... 523An embarassing situation ..................................................................................................................................... 524The causes ............................................................................................................................................................ 524Therapy ................................................................................................................................................................ 525True gynecomastia (glandular hypertrophy/hyperplasia) .................................................................................... 527

Advantages ..................................................................................................................................................... 527Disadvantages ................................................................................................................................................. 527Surgical technique .......................................................................................................................................... 530

Liposuction for pseudogynecomastia (adipose hypertrophy/hyperplasia) .......................................................... 535Advantages ..................................................................................................................................................... 535Disadvantages ................................................................................................................................................. 535Surgical technique .......................................................................................................................................... 538

Contents


CHAPTER 17 – INVERTED NIPPLE ...................................................................................................................... 543Simple correction of the inverted nipple ............................................................................................................. 545

Aethiopatogenesis........................................................................................................................................... 545Treatment ........................................................................................................................................................ 545The operation .................................................................................................................................................. 546Inverted nipple in breast augmentation .......................................................................................................... 550Hypertrophic nipple ........................................................................................................................................ 553

CHAPTER 18 – ASYMMETRIES ............................................................................................................................. 555Position asymmetry (level of insertion on the chest) .......................................................................................... 557Volume asymmetry .............................................................................................................................................. 557Case and result ..................................................................................................................................................... 559

CHAPTER 19 – MASTOPEXY AND REDUCTION COMPLICATIONS ........................................................... 569Inadequate surgical indications ............................................................................................................................ 571Implants with round block instead of vertical mastopexy ................................................................................... 572Symmastia ........................................................................................................................................................... 576Ischaemia and areolar necrosis ............................................................................................................................ 577

Perioperative ischemia.................................................................................................................................... 577Partial areolar necrosis ................................................................................................................................... 578Complete areolar necrosis .............................................................................................................................. 579

Incorrect N.A.C. positions ................................................................................................................................... 580Residual skin excess ............................................................................................................................................ 581Secondary ptosis .................................................................................................................................................. 583

Treatment ........................................................................................................................................................ 583Adipose tissue ischemia and necrosis .................................................................................................................. 588Adipose cysts ....................................................................................................................................................... 589Wound repair complications ................................................................................................................................ 591

Treatment ........................................................................................................................................................ 591Wound healing defects ......................................................................................................................................... 593

Scar Diastasia ................................................................................................................................................. 593Hypertrophic scars and keloids ...................................................................................................................... 595Dischromic scars ............................................................................................................................................ 596Infections ........................................................................................................................................................ 597Haematomas and seromas .............................................................................................................................. 598Dog ears at the ends of the scars .................................................................................................................... 598

Other complications ............................................................................................................................................. 599Sensitivity ............................................................................................................................................................ 599Carcinomas .......................................................................................................................................................... 599Secondary nipple surgery .................................................................................................................................... 599

CHAPTER 20 – ANAESTHESIA IN BREAST SURGERY .................................................................................... 601Anaesthesia in breast augmentation .................................................................................................................... 603

Preoperative evalutation of the patient ........................................................................................................... 603Preoperative tests ............................................................................................................................................ 604

Locoregional anaesthesia ..................................................................................................................................... 604Local anaesthetics ........................................................................................................................................... 604

Local anaesthesia with sedation .......................................................................................................................... 606General anaesthesia ............................................................................................................................................. 607Criteria for safe discharge .................................................................................................................................... 608Post-operative pain management ......................................................................................................................... 608

In the operative theatre ................................................................................................................................... 608In the post-operative observation or recovery room ....................................................................................... 609

Contents


Evaluation and monitoring ............................................................................................................................ 609Systemic treatment ......................................................................................................................................... 609

Non-steroidal anti-inflammatory drugs ............................................................................................................... 610

CHAPTER 21 – MEDICAL IMAGING .................................................................................................................... 613Anatomy and imaging ......................................................................................................................................... 615Clinical and imaging methodologies ................................................................................................................... 615Mammographies .................................................................................................................................................. 616Ultrasound scans .................................................................................................................................................. 618Magnetic resonance imaging (MRI) .................................................................................................................... 619Diagnostic imaging: proplems that can arise in plastic surgery .......................................................................... 619Implants and medical imaging ............................................................................................................................. 620The male breast .................................................................................................................................................... 622

REFERENCES ............................................................................................................................................................. 623

INDEX ........................................................................................................................................................................... 627

Contents


Anatomy and pathophysiology Anatomy and pathophysiology

Arterial vascularization of the breast

The blood supply to the breast is mainly guaranteed by the external and internal mammary arteries, as well as the intercostal perforating arteries, which supply blood to the inferior pole. The arterial networks, also classifiable by depth, in subdermal, preglandular and subglandul planes, are anastomosed to one another, assuring, the viability of flaps projected along very different vascular axes. Arterial vascularization is illustrated on the right with regards to the glandular/adipose structure.

Breast venous network. Breasts have an excellent venous system, the anterior superficial extremity of which coincides with the areolar area. From this area, through the subdermal plexus, the venous system runs towards the periphery and drain into the cervical and the internal mammary veins. The deep venous network (glandular and preglandular) runs predominantly through the perforating vessels into the internal mammary vein. Part of the venous drainage also flows into the axillary and the vertebral veins through the intercostal perforating vessels.

External mammary a.

Internal mammary a.

Perforating aa.

Axillary v.

Internal mammary v.

Perforating vv.

Anatomy and pathophysiology


Anatomy and pathophysiology Anatomy and pathophysiology

INNERVATIONThe breast’s sensitivity is assured by several nerve branches. The upper portion is innervated predominantly by the supracla-

vicular nerves coming from the cervical plexus (C3-C5), whilst the sensitivity of the central and lower part depends on the thoracic intercostal perforating rami (T3-T6). In particular, the medial intercostal rami, which run towards the surface next to the sternum, are distributed in the medial area of the breast and in the surrounding skin above until they terminally reach the areola.

The lateral rami, emerging from the chest at the level of the midaxillary line, run onwards and, after crossing and passing the anterior serratus muscle, penetrate the mammary parenchyma at approximately the height of the lateral edge of the pectoralis major muscle. Amongst these rami, the lateral cutaneous branch of the IV nerve is the most responsible for sensitivity of the NAC, which it reaches after crossing the gland obliquely from deep down up to the surface. Therefore the areola is innervated by a vast and widespread sensory nervous system, which almost always permits near normal postoperative recovery of sensitivity (important for sexual function and breast feeding), regardless of the mammaplasty technique used, except for that described by Thorek (amputa-tion and grafting of the NAC).

In order to increase the chances of maintaining sensitivity of the NAC, it is always good practice to leave an adequately wide neurovascular pedicle areolar flap, which should neither be excessively twisted nor compressed. Even after prolonged post-operative anaesthesia, given time, ramifications are often generated allowing the remaining intact nerves to compensate for those damaged by the operation.

Supraclavicular nn

Sensory nerves of the breast. In the superior portion of the breast sensitivity is mainly assured by the supraclavicular nerves, which originate from the cervical plexus and inferiorly by the perforating rami coming from the intercostal nerves. Amongst these, the lateral cutaneous branch of the IV intercostal nerve seems to be the main contributor to NAC sensitivity. However, ramifications amongst the nerve endings are numerous and, consequently, areolar sensitivity is usually maintained (or regained) after cosmetic surgery of the breast whatever technique is used, with the exception of that requiring NAC regrafting.

Perforating nn

Anatomy and pathophysiology


Breast Augmentation

Radiowaves in the submuscular dissection?The supero-lateral portion of the submuscular undermining is always carried out using a blunt instrument, as in that area there are

no tendinous insertions or important blood vessels and it is therefore sufficient to separate the pectoralis major from the pectoralis minor and from the rib wall, sliding scissors or a finger between the two layers. This is a physiological space, substantially without any important adherences, over which the pectoralis major can freely contract.

The situation of the lower-medial third of the dissection area is very different. Here, the sternocostal insertions of the pectoralis major muscle are found. They must be separated in order to lodge the implant and to favour partial upwards muscle retraction. These too may be released bluntly, which is anything but “atraumatic”, as the term might suggest. As a matter of fact, the blunt dissection in this area needs a certain force, often causing abundant bleeding. It is not rare to waste a lot of time searching for torn and leaking blood vessels. It is worthwhile carrying out progressive undermining of the tendons and adhesions by cautery, better coagulating veins and arteries before dividing them. In this way it is usually possible to obtain a well defined pocket, without the risk of going outside the pre-operative markings, as can sometimes happen with blunt dissection, due to the force used to detach the muscle.

Apart from the advantage of a substantially bloodless pocket and the certainty of keeping the dissection exactly within the planned limits, cautery also offers the opportunity of treating the tissues more delicately, without inducing serious trauma. The result is generally a post-operative period characterized by minor edema, modest or completely absent ecchymoses and above all, minor tenderness compared to blunt undermining.

These advantages seem to be even more pronunced with the use of radiowaves. We have had an excellent experience with the Elmann Surgitron 4.0 Dual RF, coupled with monopolar special forceps, which allows the whole dissection to be carried out using only one instrument. Besides getting hold of and coagulating the blood vessels, these forceps can also cut the tissues with their thin tips held together and can be directly connected to an aspirator, working in a perfectly clean area. An initial training period is necessary to learn the use of this instrument, because this dissection technique is actually different from the traditional method. The first times one uses this device calm and patience are needed, but pretty soon the operation can be sped up since much less time will be wasted on haemostasis.

We have carried out several tests on our patients to verify the actual reduction of post-operative pain. In 30 subjects the blunt technique was used on one side and radiowaves on the other, obtaining at first contrasting results, but subsequently verifying the “analgesic” efficacy of the more delicate dissection with radiowaves. This positive effect on post-operative pain probably also depends on the radiowave “sealing” of nerve endings and perhaps on the partial double layer undermining (dual plane), which is now used in most breast augmentation surgery. At the moment radiowave dissection is our first choice.

Radiowave dissection. A) the special dissection forceps coupled with the Ellman radiowave equipment is used to create the submuscular lodging pocket. The tube connected to the aspirator which keeps the working environment dry and smoke-free can be seen (it is indicated by an arrow). B, C) two different cases where the perfectly bloodless pockets, carried out with the described technique, are well visible. Actually, the patients that have undergone an operation with radiowaves, complain less about pain than those in whom the dissection has been carried out with blunt instruments.

A B C


Breast Augmentation

The whole dissection with only one instrument. In these pictures the use of the Stan forceps for mammary dissection is illustrated. To obtain the best results the radiowave equipment handpiece must be used without pushing the tip of the forceps against the tissue, but rather by touching it lightly and gently, using the ”coagulation” mode as much as possible, so as to obtain a substantially bloodless operation area. In pic A the dissection across the breast is carried out with closed forceps, cutting sequentially the subcutaneous fat, the gland and finally the subglandular fat. In B, the caudal portion of the gland is separated from the muscular aponeurosis. In C ,the lateral edge of the pectoralis major muscle is detected and the muscle is undermined from the costal layer and from the pectoral minor. Before incising it would be advisable to get hold of and coagulate any visible blood vessels all along the line of dissection, especially in the submuscular plane, always using the same isolated forceps. In this way less time is lost looking for a haemorrhagic spot in a bleeding area. In D, the costal insertions of the pectoralis major are gradually detached until a completely bloodless pocket (E) is created to the exact size of the implant. The prosthesis can be inserted without the need for drainage (see also notes on the previous page). In photo F, the Ellman Surgitron 4.0 Dual RF harmonic scalpel which was used in the operation described by these images.

A B

C D

E F


Breast Augmentation

Inframammary access for mammaplasty in transsexuals. Having considered the unfavourable relationship between the dimensions of the areola (usually small) and those of the implants (usually large), it is often necessary to carry out the access incision along the inframammary fold

Inframmamary scar. The inframammary incision has once again become fashionable for augmentation also in female subjects, even though it sometimes leaves slightly visible scars.


Breast augmentation: illustrated surgical techniquesBreast augmentation: illustrated surgical techniques

Local cutaneous and transglandular anaesthesia. Having sedated the patient, the local anaesthetic solution (0.25% Mepivacaine with 1: 500,000 Epinephrine) is injected along the hemiperiareolar incision line and in the area of the transglandular dissection for a total of about 8-10 cc.

Lump for the introduction of the Klein needle. A small lump is made with local anaesthetic exactly where the drainage will presumably be inserted (at the 5 o’clock position on the left and at 7 o’clock on the right, at 1 cm. from the dissection margin) and in that point a small incision is performed with the tip of the scalpel (blade 11 or 15).

Infiltration of anaesthetic behind the gland. Using the Klein needle, which is inserted into the incision, about 70 cc. of anaesthetic solution is injected between the muscle layer and the breast. The correct depth of infiltration is assessed thanks to the minor resistance offered by the virtual sub-mammary space (Chassaignac).



Cutaneous Incision. The skin is incised along the margin of the areola, following the pre-operative markings, on the right from the 5 to the 11 o’clock position and on the left from 7 to 1. To obtain a less visible scar it is best to remain slightly on the inside of the areolar edge (and therefore of the markings). The incision goes through epidermis and dermis.

Superficial dissection. Opening out the lateral wound edge with forceps (grasping the dermis), while the other edge is held in the same way by an assistant, the incision is deepened through the gland, at first with a scalpel and then by cautery at medium intensity, being very careful not to touch the skin.

Superficial dissection. The dissection is completed down to the pectoralis muscle while the assistant retracts the two edges of the wound, at first with multiple hooked retractors and then with Farabeufs.



Exposure of the premuscular layer. Having reached the pre-muscular layer, a subglandular (pre-fascial) pocket is created, first by means of blunt scissors and then with fingers so as to identify the lateral edge of the pectoralis major muscle. If soft tissue are very loose this subglandular pocket can be extended from the whole lower area up to the NAC, though in most cases it is advisable to limit it to only a few centimetres.

Preparation of the medial portion of the submuscular pocket (pectoralis major musle). Once the lateral edge of the pectoralis muscle has been identified, blunt and curved scissors are pushed against a rib (for safety), opening it out, keeping the blades parallel to the muscular layer, until a submuscular opening is created.

Preparation of the upper portion of the submuscular pocket (pectoralis major musle). The scissors are withdrawn and a finger is inserted into the opening; the pectoralis major muscle can be easily separated from the pectoralis minor in the upper region of the breast because there isn’t any adherence between the two layers.



Implant insertion. The implant which has been rinsed in disinfectant solution (Betadine or other) must only be handled by the surgeon, who before touching it, changes his powder free gloves. The assistant widens the opening, exerting greater force on the upper retractor, which lifts breast and pectoralis muscle. The implant must be squeezed and pushed with a finger on either side, into its pocket.

Implant positioning. Once inserted into the pocket, the implant must be well spread out, making sure that no folds are present and that it is placed at the correct height. Often it must be arranged in its proper position grasping its edges with two fingers. If bigger movements are need it, or in the case the implant is twisted, it is best to make it slide by first separating it from the posterior layer with a finger.

Position and symmetry assessment. Once the first implant has been inserted, one proceeds to insert the other one making sure to check, before closing the wound, that both are at the correct height and have a good symmetry. The assessment must be made by observing the breasts from every angle, both with the patient lying flat on her back and also in a semi-sitting position.



Deep suture. The edges of the glandular wound are joined with an absorbable thread (Dexon 4-0), by placing an initial stitch in the center, than continuing with a running suture from one end to the other. The more superficial wound edges (at the subcutaneous level) are joined by a second running suture, which usually goes back over the previous one (without cutting the thread), always making sure of keeping the terminal knots deep.

Superficial suture. Finally a subcuticular suture is carried out with absorbable monofilament thread (Biosyn 5-0). It is fundamental to make the wound edges meet perfectly, so that they can slightly evert, and avoid inducing ischemia through excessive tension on the thread. If the wound edges have not been drawn close enough, it would be appropriate to complete the suture with a few separate stitches in Nylon 6-0.

Dressing. Once it has been assessed that the edges of the wound match perfectly, small paper adhesive strips (Steri-strip-like) are applied obliquely. Wider tapes may be stuck over these. The periareolar wounds, as well as the drains, must then be covered by large gauze pads. These are kept in place by paper tapes.



Compressive dressing. Finally four adhesive stretch bands about 30 cm long (Fix-o-mull or Tensoplast) are applied, so that a moderate pressure is exercised. The first two are crossed over one another, while the others, applied from top to bottom, remain transversely parallel. The adhesive bands keep the breasts in the correct position, usually by pushing them in a infero-medial direction.

Case shown in the previous peri-operative images. Frontal view. Note how the necessary lowering of the inframammary fold does not cause any “double bubble - like deformity”, thanks to the scarce volume of the breast and of the implants.

Case illustrated in the previous per-operative images. ¾ view from left.



Infero-lateral subglandular dissection. The dissection is completed between the breast and the muscle fascia in the infero-lateral quadrant, exactly reaching the borders of the pre-operative markings, so that the implant can lodge adequately in that area without sliding too far to the side. On the right, the external edge of the pectoralis major muscle is evident; once this is reached in the superior pole the retroglandular dissection must stop.

Preparation of the sub-muscular pocket. Once the lateral margin of the pectoralis major has been identified, it is lifted by opening out a curved blunt scissors, leaning delicately on a rib for safety. When certain of being in the correct plane (between muscle and ribs), the scissor are withdraw and through this opening digital dissection is continued upwards and medially behind the muscle.

Preparation of the supero-medial submuscular pocket. The superomedial sub-muscular dissection does not usually present any difficulties as in this avascular plane there are no insertions or muscular adhesions. The two different undermining levels (submuscular supero-medially and subglandular infero-laterally) are therefore united in the one single plane.



Lower-medial sub-muscular dissection. If the operation is carried out under local anaesthesia or with light sedation, it is now advisable to add 5-6 cc of anaesthetic solution in the infero-medial area through the muscle opening. The tendinous costal insertions must be released, but along the inframammary fold you could try, when possible, to leave the pectoralis fascia intact, so the edges of the implant will be less visible. It is advisable to carry out this dissection by cautery (in the centre).

Infero-medial sub-muscular undermining. The sub-muscular dissection in the infero-medial quadrant must be connected to the infero-lateral sub-glandular one. The tendinous caudal insertions of the pectoralis major often need to be completely released to prevent any irregularities in the inferior profile. Finally the muscle opening is adequately widened, separating its edges with two fingers.

Insertion of drain and expander. The drain is inserted and fixed with a 3-0 Nylon suture (if a Klein needle had been used for the anaesthesia, it must come out of the same hole) and an empty expander is introduced into the pocket.



Subsequently, using the same thread, a deep suture to reconstruct the normal anatomy and then another more superficial one are carried out. Both sutures should evert the tissue outwards slightly, to avoid sunken scars. It is better to avoid superimposing knots in the same place.Superficial suture. Note in the picture on the left, it is best to knot the thread at the end of the deep suture and continue with the more superficial return suture using the same thread, so as to join the sub-dermal wound edges. If one wishes, the extremity of the more superficial

suture can be left long, so as to tie it to the end of the intra-dermal suture. This way the resulting knot can be buried easily.Intradermal suture. The external wound edges are joined by a rapid absorbable monofilament; its extremity can be tied to the preceding suture or passed to exit through the skin and cut after a few days, at the first change of dressing.



Retroglandular dissection. Through the inframammary incision (a periareolar one can be equally effective) a retroglandular undermining is carried out (left picture) that reaches approximately the level of the nipple posterior projection. To get a blood-free operation field even this dissection should be carried out by means of cautery.

Pectoralis major incision. Muscular origins are completely released along the inframammary fold. until the sternal margin. The classical retromuscular dissection is then carried out always by means of cautery, trying to avoid any direct contact with the ribs, so as to limit post-operative pain (Tebbets).

Muscle retraction. Once the submuscular dissection has been completed, notice how the muscle immediately retracts upwards by a few centimetres. In this way, the inferior portion of the implant makes full contact with the gland, supports it and improves its projection from the thoracic wall.

DUAL PLANE: SURGICAL TECHNIQUE

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