Skin Incision

The inframammary incision is commenced between 7 and 8 cm from the midline and is extended laterally following Lange’s lines. Incision length is between 3 and 4 cm but will need to be longer if textured surface cohesive gel implants are used. Dissection is carried up obliquely through the subcutaneous tissues in a cephalad direction through Scarpa’s fascia until the inferolateral border of the pectoralis major muscle is identified (▶Fig. 15.4).

Pectoral Muscle Division

The inferolateral origin of pectoralis major is grasped with an Allis tissue forceps and the muscle is divided at its origin from the ribs. Dissection is continued superomedially dividing the muscle progressively while paying meticulous attention to hemostasis. Division should be performed from 6 to 4 o’clock position on the right side and 6 to 8 o’clock position on the left side.

Perforating branches of the internal mammary artery are typically encountered at the most medial portion of this dissection. Visibility is considerably enhanced by the use of good fiberoptic illuminated breast retraction. It is often helpful to divide the muscle a few millimeters above the rib margins; this preserves a longer stump of the cut vessel for cautery or ligation and prevents retraction of the vessel into the intercostal space (▶Fig. 15.5).

Subpectoral Pocket Development

Further, subpectoral pocket dissection is undertaken using lighted fiberoptic breast retraction.

Blunt dissection using an Emory dissector or Agris-Dingman dissector should be performed carefully without risking tearing of perforating blood vessels arising from the chest wall. The submuscular dissection may be extended laterally above the serratus anterior muscle, especially in patients with a reasonably thick layer of breast tissue. Anterolateral neurovascular bundles are identified with the dissecting finger and are stretched but preserved. I prefer not to use any cautery dissection laterally in an effort to preserve nipple sensation. The dissection is carried out around these nerves to obtain a pocket of the proper dimensions. The nerves are resilient, and when necessary, these can be stretched to accommodate placement of a relatively large implant. Because the fourth intercostal neurovascular bundle contains the primary sensory innervation of the nipple–areola, its preservation is particularly important. If the fifth and sixth inferolateral intercostal branch nerves are divided, the patient will experience some hypesthesia below the nipple–areolar area. If required, an Agris-Dingman dissector may be placed at this time to stretch the pocket bluntly to further delineate the subpectoral space. When larger implants are used, this lower outer dissection is important to permit correct implant positioning (▶Fig. 15.6).

Insertion of Temporary Breast Sizers

With the pocket size and position established, a temporary breast sizer can be inserted to assess final implant volume. This can be based on a preoperative evaluation of breast measurement with base diameter calculations or it can be influenced by the use of three-dimensional preoperative breast imaging. I personally find the latter approach more satisfying as it gives the patient the opportunity to see her potential breast volume in real time. The mathematical algorithms associated with current three-dimensional imaging software are so sophisticated now that they provide an extremely good estimate of breast aesthetics. Since we have been using three-dimensional imaging, we find far fewer patients expressing regret at 6 months that their breasts are too small compared with what they would have liked. Mathematical formulae associated with breast base width assessment commits a patient to a particular volume, which may be far lower than what she actually desires from an aesthetic standpoint (▶Fig. 15.7).

Implant Pocket Lavage

There are ample data now to prove that washing the prepared implant pocket with triple antibiotic solution and/or Betadine solution is advantageous in terms of reducing capsular contracture rates. Pocket lavage with antibacterial solutions should be considered standard of care. It is our preference to utilize the formula suggested by Adams et al. We place 1 g of cefazolin, 80 mg of gentamicin, and 50,000 units of bacitracin in 1 L of saline or lactated Ringer’s solution. We also utilize a 50% Betadine (povidone iodine) wash initially, followed by the antibiotic solutions. This is particularly important if textured surface anatomical implants are used as the emerging data on breast implant–associated anaplastic large cell lymphoma suggest that there may be a link with Ralstonia pickettii contamination, an organism which is sensitive to povidone iodine in a concentration of between 25 and 50%. Prior to insertion, the implant is rinsed in antibiotic solution to facilitate its sliding through a Keller funnel. The funnel itself is also lubricated with antibiotic solution (▶Fig. 15.8).