Augmentation Mammoplasty

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Augmentation Mammoplasty

• R. Dale Reynolds, MD
• UT Houston
• Plastic and Reconstructive Surgery

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Augmentation Mammoplasty

• History
• 1895 Czerny Back lipoma ? submammary
• 1962 Cronin/ Gerow Silicone
• 1992 FDA Cancer, replacement
• 2003 FDA

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Augmentation Mammoplasty

• Anatomy
• Parenchyma

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Augmentation Mammoplasty

• Anatomy
• Blood supply

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Augmentation Mammoplasty

• Anatomy
• Nerve supply

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Augmentation Mammoplasty

• Anatomy
• Fascia

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Augmentation Mammoplasty

• Anatomy
• Muscle

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Augmentation Mammoplasty

• Patient Assessment
• Motivation
• Younger
• Older
• Normal size

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Augmentation Mammoplasty

• Considerations
• Scars
• Oncologic
• Sensation
• Pragnancy/ Lactation
• Ptosis
• Symmetry

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Augmentation Mammoplasty

• Planning

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Augmentation Mammoplasty

• Planning
• Size
• Larger chest
• Skin envelope
• Projection
• Asymmetry
• Implant type
• Smooth
• Textured

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Augmentation Mammoplasty

• Planning
• Markings
• Incision
• Inframammary fold
• Periareolar
• Axillary

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Augmentation Mammoplasty

• IMF
• Advantages
• Preserves parenchyma
• Precise pocket
• Scars well
• Best candidates
• Well-defined IMF
• No h/o hypertrophic healing
• Mild ptosis
• Sports (elevate arms)

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Augmentation Mamoplasty

• Periareoloar
• Advantages
• Scars well
• Disadvantages
• Must be AT JUNCTION
• Non-expandable difficult
• Bacterial seeding ?
• Best candidates
• Areola diameter 35 cm
• Thin layer of breast parenchyma
• Technique
• Superficial to superficial layer of superficial
  fascia to lower border of breast then into
  sub-pectoral space

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Augmentation Mammoplasty

• Axillary
• Advantages
• Hidden scar
• Disadvantages
• More difficult with rough surfaces
• Need endoscope or blind
• Revision requires different incision
• Best candidates
• Tendency to hypertrophy
• Marked hypoplasia with poor IMF
• Technique
• Mark 1.5-2 cm below IMF

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Augmentation Mammoplasty

• Planning
• Position
• Subglandular
• Good with moderate ptosis
• Active body builders
• Submusculofascial
• Decreased contracture
• Softer
• Better oncologically

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Augmentation Mammoplasty

• Technique
• Age
• Skin quality
• Ptosis
• Desired size
• Rough moves less

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Augmentation Mammoplasty

• Options

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Augmentation Mammoplasty

• Submusculofascial
• IMF

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Augmentation Mammoplasty

• Submusculofascial
• Periareolar

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Augmentation Mammoplasty

• Submusculofascial
• Axillary

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Augmentation Mammoplasty

• Subglandular
• Considerable ptosis
• Bodybuilders

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Augmentation Mammoplasty

• Subglandular
• IMF

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Augmentation Mammoplasty

• Subglandular
• Periareolar

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Augmentation Mammoplasty

• Ancillary Procedures
• Intraoperative expansion
• TE or manually
• Can use expander as estimate of
  volume
• Postoperative expansion
• Permanent expander implant
• Can alter final volume
• Abdominoplasty
• Difficult through same incision
• Biopsies
• Preop studies for all 30yo or younger if at
  higher risk
• NO FAT INJECTIONS
• Can calcify

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Augmentation Mammoplasty

• Postoperative Considerations
• Care
• Soft elastic bra or ACE
  wrap

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Augmentation Mammoplasty

• Postoperative considerations
• Massage
• Enlarges pocket
• Softens
• Can help parasthesias

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Augmentation Mammoplasty

• Postoperative Considerations
• Hematoma 0.5-3
• Good hemostasis
• Immediate post op RTOR
• Can cause some asymmetry
• Can occur 1-2 weeks post-op with increased
  activity
• Sensation 15
• 4th intercostal NV bundle most important

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AugmentationMammoplasty

• Infection 2.2
• Staph epidermidis most ducts implants
• Peri-op antibiotics
• Irrigate with iodine
• Atypical mycobacteria require removal
  capsulectomy and systemic anti-fungals
• Bacterial infections can be treated
  conservatively initially ? replace /-
  capsulectomy

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Augmentation Mammoplasty

• Capsular Contracture
• Classification
• Grade I Soft
• Grade II Minimal palpable not visible
• Grade III Moderate palpable and discernible
• Grade IV Severe hard, symptomatic, /-distortion

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Augmentation Mammoplasty

• Capsular Contracture
• Prevention
• Type
• Silicone Bleed contributes
• Textured Lower incidence, not
  axillary
• Position
• Submusculofascial better - ducts not cut
  (inflammation)
• Blunt dissection
• Less hematoma, less electrocautery, less necrosis
• Infection
• Major cause
• Pocket
• Need adequate size, larger for smooth

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Augmentation Mammoplasty

• Capsular Contracture
• Treat remote site infections (URI, UTI)
• Closed capsulotomy External pressure
  tears capsule
• Not effective, potential danger
• Open capsulotomy
• Asymmetric implant position, best for I or II
• Open capsulectomy
• Thick or calcified capsule, also smooth
  subglandular
• Conversion to submusculofascial
• Capsulorrhaphy
• Suture capsule to reposition pocket into breast
  confines

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Augmentation Mammoplasty

• Long-Term Results
• Varying degrees of firmness
• Not all contractures require correction
• Replacement Most last 7 15 years

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