Patient selection

The evaluation of the quality, volume, dimensions of the breast parenchyma and soft tissue envelope is very important. The ideal patient is slim, has adequate soft tissue coverage over the implant and good skin quality. The major cause for re-operation is breast implants that are too large for the patient’s tissue. To choose the correct implant, measurements of thorax width, the distance between sternal notch and areola, breast width, areola width, the distance from nipple to inframammary fold, and inter-mammary distance are necessary.

Indications

All the patients with the above mentioned qualities are good candidates for breast augmentation

Pre-operative preparation

At least 1 week before surgery and with the patient in the standing position, I visually analyze the body, the existing breasts and take measurements. Because I am a private surgeon I have to determine and order the implants that I use 1 week before surgery. For this reason, I cannot use sizers. On the day of surgery, I make the markings. According to the implant size, I mark the future inframammary fold and the medial, lateral and cranial pocket extent. Depending on patient preference, the incision is periareolar or inframammary. If a ptosis or asymmetry are to be corrected, the marking takes care of this problem.

The patient is placed in a supine position on the operating table with their arms out to the side at a 75 degree angle. The anesthetist begins the sedation and after careful disinfection, I start the infiltration first circumferentially with 0.5% mepivacaine and then infiltrate the medial and the lateral plane of dissection. I do not use more than 60 mL of 0.5% local anesthesia and keep the needle of infiltration horizontal so as not to provoke pneumothorax.

Technique

Depending on patient preference, the incision is made in the future inframammary line or the periareolar. The plane of dissection is retroglandular and supramuscular. The dissection is carried out under direct vision with the electrocautery. I dissect the pocket 2–4 cm wider than the implant; 2 cm wider if the skin is very loose and 4 cm if it is tight enough. If I use the periareolar approach, the incision is made to also transect the parenchyma. Caudally, the dissection is carried out to the desired inframammary line. Careful vessel coagulation is performed until the pocket is very dry. I never use drainage during the primary operation. The anesthetist administers a single injection of antibiotics.

The selected implants are placed accurately in the pocket. The implant is only exposed to the air for a few seconds. If the approach is inframammary, the superficial fascia is sutured to the profound one with interrupted 3-0 resorbable sutures. A second layer is sutured with 4-0 subcuticular sutures, and finally I use an intradermal 5-0 running suture. With the periareolar approach, the breast parenchyma is carefully closed with interrupted 3-0 resorbable sutures. If the periareolar approach is combined with a periareolar mastopexy, I first place a purse-string suture (round block suture) in the outer diameter with 2-0 nylon tightened to the chosen inner diameter. Then, 4-0 resorbable sutures are placed in the dermis. Finally, a 5-0 resorbable suture completes the closure and I tape with paper tape. In cases where I use drains (secondary cases only), these are removed after 24–48 h. A bra is worn after 24 h.

Operative steps

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  Exact drawing.

  
  
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  Pre-selected implants.

  
  
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  Careful disinfection.

  
  
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  Atraumatic pocket dissection under vision.

  
  
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  Pocket dissection 2–4 cm larger than the implants.

  
  
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  Closure in three layers with resorbable sutures (only round block suture in non resorbable nylon).

Post-operative care

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  Pain pills for 24 h.

  
  
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  Bed rest for 24 h.

  
  
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  The paper tape bandage is changed after 24 h and replaced with a sports bra.

  
  
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  The patient can resume driving after 1 week.

  
  
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  No active sport allowed for 6 weeks.