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Breast Augmentation, Endoscopic-Assisted: Treatment
Updated: May 7, 2009
Treatment
Preoperative Details
Transaxillary
Preoperative considerations include accurate marking of the native and proposed placement of the inframammary crease. Mark the first axillary crease with a 2.5-cm incision well behind the anterior axillary line. Mark the midline, proposed cleavage, and position of the partial myotomy. The myotomy should be approximately 2 cm lateral to the origins of the pectoralis muscle to avoid overdissection medially and the potential for symmastia. An example of preoperative markings is shown below.
Preoperative markings.
Transumbilical
The midline from the sternal notch to the umbilicus should first be marked in patients undergoing the transumbilical approach. A line from the umbilicus tangent to the medial border of the areola is drawn bilaterally. The markings will be used to guide passage of the mammascope.
Intraoperative Details
Transaxillary
In the operating room, place the patient in the supine position with the arms on arm boards at approximately 80°. Adherent drapes are useful at the lateral most aspect of the sterile field, since manipulation of the scope intraprocedurally can cause stapled drapes to be pushed below the line of sterility. Adherent drapes offset this problem.
Use a 1:10,000 epinephrine solution in the incision and at the position of partial myotomy. Take care when injecting the solution at the area of partial myotomy to prevent penetration of the chest wall.
Perform the incision through the axillary position with a No. 15 blade. Place 2 skin hooks and perform vertical spreading through the subcutaneous tissues until the pectoral fascia is reached. Follow the undersurface of the upper skin flap to the fascia to avoid injury to the intercostal brachial nerve. Insert the index finger, identify the underside of the pectoralis, and perforate the fascia to allow access to the submuscular plane.
Insert the endoscopic retractor, followed by the scope. The author uses the Emory-type retractor. Insert a 10-mm Hopkins rod endoscope within a sleeve in the retractor. After establishing the optical cavity, insert the endoscopic Bovie. Place low-wall suction on the endoscopic Bovie unit. Perform superior retraction with gradual enlargement of the pocket.
Commonly, an assistant holds the retractor during dissection; however, the need for this assistance is diminished with experience. Constantly assess the internal position of the retractor with relation to the breast external anatomy by looking at the scope's transillumination through the skin and by watching the tissues move through the scope during manipulation of the external breast tissues. If necessary, several Angiocaths can be placed through the skin after superior retraction is performed to guide the myotomy during early experiences.
The myotomy of the pectoralis muscle origin is usually performed from the 3- to 6-o'clock position approximately 2 cm off the chest wall. The dissection proceeds superomedially to inferomedially. Perform the inferior dissection with care to avoid overdissection. Also, avoid overdissection or underdissection medially. A complete myotomy and incision of the pectoral fascia is necessary to achieve marked improvement in cleavage; however, in thin patients with minimal breast coverage, this can lead to rippling medially. Underdissection medially can result in a lack of a defined cleavage and superolateral implant malposition.
Thoughtfully determine the amount of inferior dissection needed to accommodate the dimensions of the implant chosen, based on the ideal transverse base diameter. In thin patients in whom a significant fold alteration is performed, the result can be a markedly palpable implant inferiorly. A bottom-heavy breast and possible inferior implant displacement can result from overdissection of the inframammary crease. Tapping of the inferior crease is a useful postoperative adjunct to set the crease during the postoperative period. Underdissection inferiorly can lead to superior implant displacement. An upper-pole strap can be useful postoperatively, especially in a breast with a tight lower pole, to set the implants in the lower part of the pocket.
Remove the endoscope and Bovie, and insert a deflated saline implant. A smooth implant surface is chosen almost universally. Roll the edges toward the center, and insert the compact implant with the help of Army-Navy retractors. Take care to avoid dissection or implant placement below the pectoralis minor. The implant is then inflated. Carefully dissect the lateral pocket with the index finger to avoid overdissection or injury to the sensory nerves. Refinement of the inferior and medial pocket can be achieved further with a large urethral dilator or a Dingman dissector. Place the patient in the sitting position to verify implant position and volume requirements.
Remove the fill tubes, and place the check caps. Close the axillary incisions with a layer closure followed by benzoin and a Steri-strip. No drains are used.
Transumbilical
Position the patient supine with arms extended to 90 degrees. Prepare and drape the patient in the standard fashion, leaving the chest and anterior abdominal surface exposed. An umbilical ring is elevated by the assistant using skin hooks at the 12-o'clock and 6-o'clock positions. The procedure necessitates an incision large enough to allow passage of the index finger without resistance. Scissors are used to then dissect superiorly onto the abdominal fascia.
Insert the mammascope through the umbilical incision. Pass the mammascope through the subcutaneous tissue while tenting the skin and subcutaneous tissue with the opposite hand. Follow the muscular surface and cross the costal margin. Then enter the fascial plane beneath the breast as the breast is tented away from the chest. The sudden decrease in resistance and advancement of the endoscope signal insertion into the fascial plane beneath the breast. Advance the endoscope superior to the nipple. Then, remove the internal obturator.
Determine correct placement of the endoscope by visualization of the tissue planes. The undersurface of the breast is light yellow in color, whereas the muscle appears reddish brown. Newer reticulating endoscopes allow greater adaptability with regard to visualization. With the ability to change view without moving the handpiece, less torque is generated at the incision, and the field of vision is greater in general. This also allows greater mobility of instrumentation, with a fixed handpiece positioned so as to prevent obstruction.
Evacuate the air from a posterior leaf valve implant and coil it in a cigar-like fashion. Connect the fill tube to an extension tube with a stopcock valve through the lumen of the mammascope. Insert the coiled implant into the open end of the mammascope and gently push it into the umbilical incision. Following insertion, push the implant with the fill tube insertion site facing the abdominal wall into the breast. Use the opposite hand to stabilize the implant as the mammascope is withdrawn, taking care not to dislodge the fill tube from the implant prematurely.
Inflate the implant to 150% of the desired volume. With excess saline in the implant, manipulate the implant externally in all directions. Clamp the fill tube and remove the extension tube. Approach the opposite breast in the same manner. After overfilling and further external manipulation, remove the excess volume and remove the fill tubes on both sides. Reinsert the mammascope on each side to visualize the implants. This confirms implant integrity and hemostasis. Finally, withdraw the mammascope and close the umbilical incision.
Postoperative Details
Postoperative management is straightforward with both methods. Place dry gauze over the respective wounds for 24 hours. Steri-strips remain until the suture is removed at 10 days to 2 weeks. An upper-pole strap is worn for several days to several weeks, depending on the tightness of the inferior pocket. This forces the implant in an inferior direction. Massage of the implant pocket is begun at 2 weeks.
Complications
- Complication rates for these procedures are comparable with other techniques for breast augmentation.7
- Implant malposition: Most implant malpositions are related to superior displacement; however, inferior displacement with bottoming out is more difficult to treat. Inadvertent subpectoral implantation has been reported in the transumbilical approach. This occasionally cannot be corrected remotely and requires an inframammary incision.
- Axillary banding: Fibrous banding across the axillary incision is believed to be either lymphatic channels or thrombophlebitis (Mondor disease).
- Hematoma: Although meticulous hemostasis is one of the benefits of the endoscopic approach, axillary hematoma has been described, although rarely.
- Deflation: Published reports suggest these complications to be similar to those of any other technique.
- Capsular contracture
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References
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Spear S. Editorial comments on transaxillary breast augmentation. In: Surgery of the Breast: Principles and Art. Philadelphia, Pa: Lippincott Williams and Wilkins; 1998:893.
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Further Reading
Keywords
transaxillary approach, breast augmentation, transaxillary endoscopic augmentation mammaplasty, breast enlargement, breast enhancement, endoscopic breast enlargement, endoscopic breast enhancement, endoscopic breast augmentation, mammoplasty, breast implants, breast revision, mammaplasty
