Surgery Spotlight: Inframammary Fold Subpectoral Silicone Gel Breast Augmentation-Surgery Spotlight: Inframammary Fold Subpectoral Silicone Gel Breast Augmentation

Surgery Spotlight: Inframammary Fold Subpectoral Silicone Gel Breast Augmentation

Video Transcription

I'm Dr. Rod Roark, I'm the Professor and Chairman of the Department of Plastic Surgery at UT Southwestern Medical Center in Dallas, Texas.  Today we're going to take a look at how I approach breast augmentation. In this particular patient we're going to do an inframammary fold, subpectral, silicone  gel breast augmentation. Breast augmentation is one of the most common operative procedures that's done in the United States today for cosmetic surgery.  The goal is to show you how to do it in a very safe, simple, and effective manner in the operating room under a general anesthesia.  The breast augmentation patient, if managed well preoperatively and intraoperatively, does well postoperatively. The major concern is how to appropriately evaluate these patients.  As we will show, the markings on the patient, the use of the base diameters, the breast parenchymal amount, the degree of breast ptosis, these all interplay into the decision making  process for the proper sizing that you'll see in this operative procedure. The role of silicone gel implants versus saline implants is also clarified.  Both are very safe and useful implants. They both have a life span and they both have inherent advantages and disadvantages.  In the patient we're going to show today, we're going to be demonstrating a smooth rounds classic implant, placed subpectrally, silicone gel.  The basic method of measuring a breast augmentation is using multiple parameters, but the base dimension is actually one of the most important.  Her base dimension is about 14 centimeters, and I think that's important.  She's moderately wide on this area, and she wants to be just fuller in the upper pole and just back to before she had children. That's in the moderate C cup range.  What we're going to do is we will mark her for an inframammary fold subpectral breast augmentation with silicone gel implants, smooth silicone gel.  We're going to be using moderate profile because her base diameter is fairly wide, and she wants a more natural look, subpectral with a gentle slope, but some fullness.  Using the base diameter of 14 centimeters, that puts her in the range, and I'm going to be using Mentor Classics in the 360, 380 size range, bilaterally.  We will go, and the inframammary fold is well defined in her. It's right below the meridian of her nipple, and we measure that to confirm it.  That's 10 and a half centimeters on both sides. We will always measure, and everybody's asymmetrical.  That's pretty normal, so 10, 10, and then we go, we'll do in the fold in her bilaterally,  and we'll mark those again, and basically, it's basically in a, it's a four centimeter incision from the breast meridian, and so we'll do four centimeters, and I like to go  right into the fold itself, especially in somebody that I'm going to be just augmenting to really restore her previous volume.  Then one of the major considerations is we're going to go inframammary fold, subpectral, and then the dissection will proceed up into this area, and then it'll go sweeping medially,  and then superiorly, and then laterally, and then the lateral sweep, the lateral will be mainly a dissection just to fulfill the volume we want on the base diameters.  This is all done with electrocautery under direct visualization, so as you can really maximize the exposure of the pectoralis major, and then we will release the pectoralis major  muscle on its insertions just to the peristernal areas right here, so we'll release it to a about this area on both sides.  She's volumetrically going to do very well because we're really refilling her to where  she was after having her children, so I think this is an ideal patient for a breast augmentation.  So we're going to go inframammary fold, so the first thing we do, we've already preinjected her with lidocaine, and I'll just mark on the skin where, so we'll go to the pectoralis  major, we'll find it, there's always a little bleeder here, we'll get that, and then we'll go medial, superior, and then lateral, and this is really where we'll end up, and this  will allow us to stay away from the pectoralis major, or minor, as we do this dissection. And then our release will be, if these are the fibers of the pectoralis major, our release  will be just leaving a few of the pectoralis major fibers and we'll release it in that area almost to the peristernal area.  We're going to go initially with the double hooks, and we're going to go down to the chest wall, and then once we're down through the breast tissue, we will then replace with an  army navy, and again, the goal here is to get to the lateral portion of the chest wall, the lateral portion of the pectoralis major, and I'm just seeing it right there, and I'm  elevating, and remember, when you're elevating, the thing that comes up, that's the pectoralis major, and then we're going to go in with the lighter retractor, so I'm on the lateral  border of the pectoralis major, just going into the pectoralis space, subpectoral space here, it's in a realer area.  I'm now going to sweep more medial, there's a little bleeder there, as we talked about, I'm going to bogey that, and again, this is attributed to Dr. Tebitz, who really told  us about the rationale for doing this, using electrocautery, staying off the pericondrium as much as possible, it does diminish pain, postoperatively, versus the blunt dissection.  So I'm releasing the pectoralis major in this area here. I'm releasing it until I see some glandular tissue, and the key is, just release it to  the parasternal area, just to the sternal portions. You want to not over-release it, especially in a patient that doesn't have very much breast tissue.  So we're doing that, and then I'm going to go superiorly now, so I'm going to go along, in this area, she's fairly broad.  So we're sweeping, so we've gone, we've released the pectoralis major fibers up into the sternal area, we've left those in place, and then we've gone superiorly, and now we're going  laterally. We're below the pectoralis major and above the pectoralis minor. And then the key laterally is to sweep, but not to bogey excessively, especially when  you're around the area laterally, along the fourth anterior portion of the intercostal, where the innervation to the nipple is.  So you want to really, I like to just dissect that out and push laterally. I don't like to just, I don't like to do a lot of bogeying here.  So I've actually swept this whole area clean, and usually you do the lower 70% or so, the sharp dissection, and then what I do is I'll bring in just a, this is an old Dingman dial  elevator, that actually, this is how we used to do entire breast dogs, and all this does is just allow you to see the shape of your pocket.  So you can see where we've released the pectoralis major, and where our dissection is along the  peristernal area, and then also you can see where you've done your dissection laterally. And I like to, with my sizer, get my final dissection laterally.  I don't like to do a lot of dissection laterally because I don't want to over-dissect it, especially in a patient like this that's got a really broad base diameter.  You don't want to be displacing them. So let's size it. So we're going to size her based upon her base diameter of 14 centimeters with a moderate gel implant. This is mentor type.  I have no interest in any of these implants. I'm just, so we'll size it. This is a three. And all I'm doing is I'm just feeling to see where my base diameter is, and she looks like  she's filling that out quite nicely. And what we'll do is we'll now proceed and do the same on the other side.  And then I'll sit her up to see how she looks, and we'll sit her up and take a look and evaluate her for any asymmetries that she may have and whether we need to put in a different  size implant. So again, we've swept superiorly, and I'm going to just do the areolar plane dissection superiorly with the Dingman. That's all we're doing.  And just making sure we're in the same area. So I'm going to put in a 405 classic profile. So this is a, it's also within the base dimensions of her, within 14 centimeters.  I think this is 13.9. So let's sit her up, and we can see what she looks like. You know, we sized her, and usually, you know, she doesn't have that much discrepancy, but  I put a 405 on this side and a 385 on this side. And actually, I actually like the right side more, and so does everybody else.  So let's fly her down a little bit, just sit her down just for a second. So you know, it goes back to the philosophy of if you have this, only a mild amount of  asymmetry, then don't put in a different size implant. You know, and I think she looks quite symmetric, both superiorly, laterally, and medially.  And she has, you know, she has some nipple asymmetry, and that, of course, is not enough to do a lift or anything, and that's certainly within normal limits.  But I think volumetrically, she looks very good. I prefer the inframammary fold subpectral approach in a high majority of my patients  for several reasons, primarily because it gives you ease of access in correction of all types of breast asymmetries and deformities.  It allows you to release the muscle, do a dual plane breast augmentation if needed, do interoperative corrections under direct visualization.  And of course, I go subpectral because it has been shown that there's statistically significantly less capsule contractures in both silicone gel and saline implants.  And in the use of saline versus silicone implants, a lot of that is determined by the patient and the surgeon interaction.  I use 50% to 60% saline implants in cosmetic augmentation patients, and the rest in silicone gel. But it just depends on the patient.  And in this particular patient, she had a moderate amount of breast tissue, and she wanted some more fullness.  And after discussing the advantages and disadvantages, we decided for silicone gel. And we use smooth versus textured implants in all primary breast augmentation patients.  The difference in the base diameter between the 385 was 13.9, and this is 14.2 for the 405. And sheer base diameter is 14 centimeters. So it actually works out very well.  So the next critical thing is hemostasis. And I like to get absolute hemostasis. And so you'll see I'm going to irrigate first.  And in Texas, we want it to be clear or looking like Texas tea when we're done, right? So we're going to irrigate first before we do any hemostasis. She looks pretty good.  It's almost close to Manhattan tea, but this is going to be Texas tea. But the goal is to get hemostasis.  You know, obviously, one of the causes of capture contracture is hematoma, and we want to make sure of that. So that actually is very good. That's without any hemostasis.  So that's pretty good. And then we'll do the same on Dr. DeBal's side. And then we're going to get some hemostasis.  I think John Tebbets needs to be credited with really popularizing this technique of doing this under direct visualization, because so many of us were taught to do it in a blunt  manner. And I think that that really probably was not the best, both for patient comfort and for hemostasis control. If you look at that, that's pretty good.  And then we do use triple antibiotic solution to... Yeah, I'm ready for the triple antibiotic solution.  And I think triple antibiotic solution is, you know, as Bill Adams and our group here at Southwestern has described, it really does work very well.  I think anything you can do to decrease the inherent potential for infection, you should do so. We change gloves, use talk-free gloves, and then we will place the implant.  So we change our gloves. We use, obviously, talk-free gloves. And the implant has been soaking in triple antibiotic solution for at least...  And we have some more triple antibiotic solution that's in here. It's been soaking, and so is the other one. And so we...  And then we also do that with our Army-Navy, and so we place the implant in. And obviously, the sizers are not completely...  These silicone gels are a little bit, I find them to be a little bit bigger, and in this  case, it'll actually help her. Certainly, in somebody with this base diameter, it doesn't look like she's got a 405cc implant  in place, but that's indeed what, you know, she measured out to be and what she looked like. And I think that's why, to me, sizing them interoperably is still important.  I mean, certainly, the base diameter matches. It's 14.2 centimeters, but I think it still matters to size it. And I think that it's still very good practice.  I know some people say, you don't need to size it, but, you know, if it adds five minutes or less to give you the results you want, I think that's appropriate, and that's what I do.  So I think one shouldn't be, you know, beat up for sizing an implant or putting a patient implant in by sizing first. So again, and it's done with upward pull.  And I usually don't sit her up again, but we will today just to show the result. So we'll sit her up. I released the pectoralis major a little bit more on the right side.  I didn't really need to do a dual plane. So let's take a look. And I think she looks good. So I think she's got good symmetry.  I mean, obviously, she still has some asymmetry from her pre-op in that she has a little more ptosis on the left and the right, but I think volumetrically, she's very good.  We'll do a deep layer closure with 3-O-Vicryl and 3-O-Vicryl. I use Marcane half percent irrigation in the pocket. I think that's important.  And then I use some Marcane to point, this is half percent Marcane plane.  We inject it into this area. And then we close the rest of this with 4-O-Vicryl and then some 5-O-PDS. Obviously, I did it in the inframammary fold, and that's where it's staying.  But I'll go into the deep fascia, close that, and put in three sutures on the knot. Yeah, thank you.  And really, within three weeks, they're back. I mean, they're fairly comfortable in a day or two. We give them some Valium just for muscle relaxants for their muscle,  some pain medication if they need it. Many times, they'll just need it for a day or two, and then they're on their way.  I think the biggest thing is we have to restrict them from getting their heart rate above 100 for the first three weeks. After that, I let them do really what they want to do.  This is Dermabond. You can use anything else again. I like it because they can shower 24 hours, no need for having stitches out.  Breast augmentation  I certainly hope that we've demystified breast augmentation for you and made it simple, safe, and effective. And when I say simple, I don't mean easy to do,  but something that will allow you to get consistently good results in your patients, that will not only allow you to have satisfied patients,  but will allow you then to use these techniques as the patient ages when you're replacing the implants and actually doing other things  like implantation removal and replacement and breast augmentation and or mastopexy in these patients as they age. And as all patients age, their implants will have to be exchanged,  their breast tissue will change, they will get breast ptosis. So many of these patients may need to have implant exchanges and a mastopexy or a lift later on in life.  MedicalCityHospital.com

Video Summary

Dr. Rod Roark, Chairman of the Department of Plastic Surgery at UT Southwestern Medical Center, outlines his approach to breast augmentation, a prevalent cosmetic surgery in the U.S. He details a procedure involving inframammary fold, subpectoral, silicone gel implants. Dr. Roark emphasizes preoperative and intraoperative evaluations, including base diameter and breast tissue assessment, crucial for optimal sizing and postoperative outcomes. He compares silicone and saline implants, highlighting their respective safety, lifespan, and pros and cons. For this patient, a smooth, round, moderate-profile silicone gel implant is chosen, aiming for a natural look and fullness. The surgical process involves meticulous dissection and release of the pectoralis major for implant placement. He underscores achieving absolute hemostasis and infection prevention, advocating for direct visualization and sizers to ensure consistency and satisfaction. Postoperative care is essential for recovery, with restrictions on activity to ensure optimal healing.

Asset Caption

In this video, Rod Rohrich, MD performs a breast augmentation using silicone gel implants on a woman who wishes to regain the upper pole fullness she had prior to pregnancy. In this video, Dr. Rohrich discusses the benefits of using the inframammary fold, subpectoral approach with a smooth, round silicone gel implant. He demonstrates the markings for the operation and the rationale behind them, and discusses how breast diameter, base dimension and ptosis play into decision-making for proper implant sizing. During the operation, he demonstrates the elevation of the pectoralis major and the importance of not “over-releasing” the muscle in patients without a lot of breast tissue. He shows the aureolar plane dissection, and discusses his preference in placing implant sizers prior to final implant placement. He also discusses the importance of establishing hemostasis to prevent capsular contracture, his procedure in using triple antibiotic solution after hemostasis has been achieved, and his methodology for closure and post-surgical care.

Surgeon Rod J. Rohrich, MD

Disclosure Dr. Rohrich has a book royalties relationship with Quality Medical Publishing and an instrument royalties relationship with Micrins Instruments .All ASPS staff members managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials. This product is not certified for CME.

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Rod J. Rohrich MD; Memben