Submuscular Periareolar Approach to Augmentation Mammoplasty in Korean Women

Augmentation mammoplasty can be approached by various methods according to the type of implant and implantation site depending on the status of the patient or surgeon's preference. The advantage for submuscular placement is based on problems associated with subglandular placement, especially capsular contracture and sensory changes in the nipple, and interference with the interpretation of mammograms is avoided. There are fewer complications such as hematoma, infection, and extrusion of the implant with submuscular dissection and relatively avascular, minimal sensory changes in the nipple compared with subglandular approach. The submuscular periareolar approach to augmentation mammoplasty was first described in the 1970s. This approach provides easy access to both the subglandular and subpectoral planes. It also provides a central point of access for creation of the implant pocket, which allows for easier and more accurate dissection in all diameters. The resultant periareolar scar is usually minimal with less injury to breast parenchyme and eventual biopsy or mastectomy incision to be performed through or around the areola. During the period of March 1999 to January 2000, 19 cases of who received submuscular periareolar augmentation mammoplasty under general anesthesia resulted in favorable scars with accurate access to pocket margin, easier dissection, and less bleeding compared with submuscular transaxillary augmentation mammoplasty. In our experience with the submuscular periareolar approach to breast augmentation it was highly versatile, safe, and less painful; postoperative hematoma incidence was greatly reduced and breast tissue injury was minimized.     

改良乳晕切口隆乳术及假体置放技巧

为了更好地开展乳晕切口隆乳术，我科自１９９４年以来，对７例患者采用改良的乳晕内上或内下弧形切口，及单指置放假体的技巧，在胸大肌下间隙置放硅凝胶假体，术后乳房形态满意，随访３个月至１年无乳头乳晕感觉减退，感觉异常及纤维挛缩等并发症。本方法通过小切口置放大容量假体，手术操作简便易行，避免了神经损伤，使切口隐蔽的乳晕切口隆乳术具有更高的实用价值。     

Partial Myotomy of the Pectoralis Major in Submuscular Breast Implants

Several authors report that retropectoral or submuscular placing for prostheses reduces the incidence of capsular contracture, preserves the sensitivity of the areola, and gives the breast a more natural look; however, displacement of the prosthesis when contracting the arm, shoulders, and thorax muscles is often observed. In order to prevent this deficiency, partial thickness myotomy was performed in the pectoralis major muscle. Since 1987, our team has carried out 120 subpectoral augmentation mammoplasties by submammary approaches using this procedure. The ages of the patients ranged from 19 to 44 years old. In all cases, physiological saline microtextured prostheses were used. Volumes were between 225 and 275 cc. The results were satisfactory in all cases, with no hematomas, infections or capsular contractures. The main advantage of this technique is that it prevents displacement of the prostheses after movements of the arms or shoulders.     

Submuscular augmentation mammaplasty using a perinipple incision

The periareolar approach for submuscular augmentation mammaplasty sometimes shows a widened or hypertrophic scar and distorts the shape of the areolar-skin junction. The authors describe submuscular augmentation mammaplasty using a perinipple incision and muscle preservation techniques. The perinipple incision can be extended using a backcut within the areola according to the thickness of the index finger of the operator. The authors could reach the lateral edge of the pectoralis major and lift it while preserving anatomic continuity. The folded, smooth saline implant was introduced with a no-touch or minimal-touch technique. Implant volumes ranged from 175 to 325 mL. Ten to 25-mL volume was overfilled (within the recommended amount), particularly large volume was overfilled in patients who had a thin envelope to reduce the palpation of the edge of the implant. From August 2000 to December 2002, 306 patients underwent subpectoral augmentation mammaplasty via the perinipple approach. Eleven patients complained of rippling or a visible fold. There were 7 patients who required a partial capsulectomy through the perinipple incision again. The scar was well hidden but scar revision was needed in 17 patients as a result of skin slough on the areola flap. Of these cases, some were camouflaged using a medical tattooing procedure as well. Pain was reduced markedly compared with the axillary approach. In conclusion, the perinipple incision has a less visible scar in patients who have an ill-demarcated skin-areolar junction and provides a similar operative field compared with the periareolar incision. In addition, preservation of the normal skin-areola junction is cosmetically successful.     

内窥镜辅助隆乳术

目的 养活常规隆乳术盲视下操作分离假体置入腔隙而赞成的创伤,提高隆乳术效果,探讨内镜在隆乳术中的应用。方法 自1996年5月起在内窥镜辅助下行胸大肌下置入腔隙的分离,止血及肌肉,筋膜的剥离,切割,17例置入假体34个,其中经腋切口7例,乳晕旁切口9例,乳房下皱臂切口1例。结果 应用内间辅助进行隆乳术可以减少组织损伤,经乳晕旁切口可以更直接和准确地分离和切割胸大肌内下份起点,腹直肌前鞘和腹外斜肌筋膜,形成分离彻底的置入腔隙和良好的乳房下皱襞形态,防止乳房假体上移及位置不正,术后无出血,感染等并发症,10例术后经随访3－12月,均无包膜挛缩,外形及手感良好,结论 内窥镜 乳术对置入腔分离,止血彻底,可减少血肿,感染等并发症,降低包膜挛缩的发生率,有助于获得良好的手术效果。     

Unsatisfactory results of periareolar mastopexy with or without augmentation and reduction mammoplasty: enlarged areola with flattened nipple

A method of repair is described for correction of abnormally enlarged nipple–areola complex following both periareolar mastopexy and pregnancy. Although during periolar mastopexy or reduction mammoplasty regular subcuticular dermal sutures may control the enlargement of nipple–areola complexes initially, the periareolar scar becomes hypertrophic and areolar spreading occurs to some extent. Periareolar mastopexy techniques are indeed advisable only for minimal hypertrophies or ptosis of the breast, especially for areolar asymmetry, if an acceptable, normal-size areola is expected. The authors believe that in periolar mastopexy or reduction mammoplasty cases resulting in enlarged nipple–areola complexes, the size of the areola can also be corrected by reduction mammoplasty or mastopexy using vertical bipedicle techniques. Although surgery results in an inverted T incision, the shape of the breast is more acceptable and the size of the areola does not enlarge with time.     

隆乳术后包膜挛缩处理方案探讨

目的:探讨直视下经乳晕切口对假体隆乳术后不同情况下包膜挛缩的有效处理方法。方法:2009年1月～2012年10月,对65例假体隆乳术后包膜挛缩进行治疗,均采用乳晕切口,视原假体植入腔隙及乳腺、胸大肌厚度等条件采取重新剥离腔隙、去除或不去除包膜组织甚至Ⅱ期手术的方法,术中严格止血。结果:本组65例术后均获得随访,随访时间8个月～42个月,平均随访时间15.2个月,术后包膜挛缩复发者2例,其余病例乳房外观均满意。结论:应用直视下乳晕切口对假体隆乳术后包膜挛缩进行个性化的有效处理,术后包膜挛缩复发率较低。     

Wise pattern mastectomy with immediate breast reconstruction

A new technique of immediate breast reconstruction is presented. This technique uses a silicone implant placed in a subpectoral pocket, using de-epithelialised skin from the lower breast to augment the submuscular pocket, thus producing a compound myodermal flap. The technique is simple, and the resulting scar is cosmetically satisfactory; when combined with reduction mammoplasty on the opposite breast, this technique produces satisfactory breast symmetry.     

Subfascial Endoscopic Transaxillary Augmentation Mammaplasty

Video endoscopy for breast hypoplasia and glabellar frown lines has been used since 1996 at our private clinic. Breast augmentation with an S-shape incision for transaxillary access is utilized to introduce the implant, in a submuscular or subglandular and, recently (since October 1998), in a subfascial location. From August 1998 through January 1999, 62 patients underwent endoscopic surgeries; 49 were submuscular, 5 subglandular, and 8 subfascial. McGhan 410, anatomical biodimensional implants 155 to 235 g, were used. We observed three cases of complications, two of them malpositioning (rotation), needing reoperation, and one hematoma, treated with drainage. Patient satisfaction was high, especially regarding the axillary incision. There have been no capsular contractions to date.     

聚丙烯酰胺水凝胶注射隆乳后的并发症及治疗

目的探讨聚丙烯酰胺水凝胶（polyacrylamide hydrogel,PAHG）注射隆乳后的并发症及治疗方法。方法对l74例术前行乳房超声或磁共振成像（MRI）检查以确定PAHG分布范围。采用乳晕切口行组织分离,生理盐水灌洗,清除PAHG,切除异常组织;其中对继发乳房畸形者选择性地以胸大肌后间隙假体置人进行修复87例（50％,48例I期,39例Ⅱ期）。结果术后随访3～6个月,绝大部分症状得到缓解。77例（44．3％）对乳房外形、手感满意;10例（5．7％）对手感不太满意;79例（45．4％）出现乳房下垂或扁平胸;8例（4．6oA）出现较重的乳房畸形。结论PAHG注射隆乳术后出现并发症者,应尽早清除,治疗方法得当可取得较好疗效,但完全满意者较少。穿刺盲视抽吸的方法不可取,以开放式手术为佳,有强烈要求及条件允许者可行乳房假体置人重建术。     

Augmentation mammaplasty by medial periareolar incision

Various techniques and different types of incisions have been used for breast augmentation, the choice of which depends on regional and physical characteristics of the patient, an indication for the operation, and the decision of the patient and the operator. The periareolar approach is ideal for cases of developmental hypomastia that have adequate skin and glandular tonus and with minimum ptosis. The disadvantages of this method are a hypopigmented scar on the pigmented areola and a decrease in sensitivity of the nipple-areola. This article presents the experiences of the Department of Plastic and Reconstructive Surgery of the University of Istanbul, Faculty of Medicine between 1995 and 1998, on medial periareolar submuscular augmentation approaches to five cases. During this follow-up period we had no major complications.     

Breast augmentation: a review of subglandular and submuscular implantation

A study of 156 patients who underwent augmentation mammoplasty at the Medical College of Georgia from June 1980 to July 1985 is presented. Complete records on 89 patients with 196 implants were obtained. A retrospective analysis with respect to capsular contracture was undertaken. Possible influential variables including age of patient, type of prosthesis, operative blood loss, use of local steroids, and site of insertion (i.e., submuscular versus subglandular) were considered. The site of implant insertion was the only statistically significant factor affecting capsular contracture. The incidence of capsular contracture was 9.4% with the submuscular approach and 58.0% with subglandular contracture. The followup time for the submuscular group was 17.4 months (range of 6-36 months) with the mean time of capsule contracture occurring 4.5 months after insertion. There were no significant differences in intraoperative blood loss or elapsed operating time between the submuscular and the subglandular placements of the prosthesis. This study confirms the submuscular technique of augmentation mammoplasty as the most reliable method of reducing the high incidence of capsular contracture.     

聚丙烯酰胺水凝胶注射隆乳术后哺乳期并发症的处理

目的 探讨聚丙烯酰胺水凝胶注射隆乳术后哺乳期并发症处理的有效方法.方法 对13例行聚丙烯酰胺水凝胶注射隆乳术后在哺乳期并发乳汁淤积、乳漏、急性乳腺炎等患者,采取手术切开清除水凝胶及淤积乳汁、放置引流管、术区加压包扎,并结合有效的药物抑制泌乳等措施予以治疗.结果 13例术后7～15 d全部治愈.随访3个月至4年,效果满意.结论 切开清除水凝胶及淤积乳汁、持续引流,结合有效的药物抑制泌乳措施,是治疗注射隆乳术后哺乳期并发症的有效方法.     

Breast augmentation: A review of subglandular and submuscular implantation

A study of 156 patients who underwent augmentation mammoplasty at the Medical College of Georgia from June 1980 to July 1985 is presented. Complete records on 89 patients with 196 implants were obtained. A retrospective analysis with respect to capsular contracture was undertaken. Possible influential variables including age of patient, type of prosthesis, operative blood loss, use of local steroids, and site of insertion (i.e., submuscular versus subglandular) were considered. The site of implant insertion was the only statistically significant factor affecting capsular contracture. The incidence of capsular contracture was 9.4% with the submuscular approach and 58.0% with subglandular contracture. The followup time for the submuscular group was 17.4 months (range of 6–36 months) with the mean time of capsule contracture occurring 4.5 months after insertion. There were no significant differences in intraoperative blood loss or elapsed operating time between the submuscular and the subglandular placements of the prosthesis. This study confirms the submuscular technique of augmentation mammoplasty as the most reliable method of reducing the high incidence of capsular contracture.Presented at the annual meeting of the Southeastern Society of Plastic and Reconstructive Surgery, Boca Raton, Florida, May 27, 1986     

An Uncommon Complication of Secondary Augmentation Mammoplasty:Bilaterally Massive Engorgement of Breasts After Pregnancy Attributable to Postinfection and Blockage of Mammary Ducts

Augmentation mammoplasty is one of the most frequently performed aesthetic operations. Galactorrhea and galactocele formation after augmentation mammoplasty, while the patient is experiencing the hormonal effects, is rarely seen. The cause remains unknown. However, postoperative fibrosis and blockage of the mammary ducts after augmentation mammoplasty is a probable cause of this formation in some patients. In the reported case, the patient described painful massive engorgement of both breasts during the last month of pregnancy and inability to breast-feed after delivery. In her history, she had undergone breast augmentation via the semicircular periareolar transglandular approach. She had experienced an infection at an early stage of her postoperative period and had needed to have both prostheses removed. A second breast augmentation mammoplasty was performed 1 year after the first operation via the same incision. She was content with the result of her second augmentation mammoplasty, up until her third pregnancy, at which time she reported inability to breast-feed after her delivery. At our examination, it was determined that there was massive painful breast engorgement, hyperemia, and inflammation of both breasts attributable to a bilateral galactocele formation. She refused to take any medication (bromocriptine), but approved antibiotic treatment. The patient responded to the antibiotics, and the prostheses therefore were left in place without further complications.     

Our Experience with the Triple-V Transareolar Incision for Augmentation Mammaplasty

There have been many important analyses of prosthesis selection, techniques of implantation, and subpectoral or subglandular pockets, but only a few studies comparing and discussing the different approaches. The best incision must achieve a good and simple approach to the retromammary location, subpectoral or subglandular, preserving the anatomy to maintain the nerves and vessels responsible for the sensitivity and blood supply of the breast and avoiding cutting the ductus, and it must result in an inconspicuous scar. This article reports the authors' experience with the last 100 consecutive patients operated on with the triple-V transareolar technique based on the original reported by Ely. Follow-up took place over more than 2 years. The authors discuss the advantages and disadvantages of different incision placements.     

Periareolar mastopexy with mammary implants

We present our experience with using a periareolar mastopexy technique combined with prosthesis implantation to correct mammary ptosis, misplaced areolas, and tuberous hypoplastic breasts. We draw a circle around the areola and deepidermize the skin between them. We enter the glandular tissue and introduce the implant in a submuscular pocket. A purse string suture of nonabsorbable material is used to gather the excess skin. Results were satisfactory in all cases. During the immediate postoperative weeks the shape was flatter and protruded less, but a progressive correction was observed. The tuberous breast could be released and reshaped adequately. Misplaced areolas can also be replaced correctly by drawing the periareolar circle and ellipse in eccentric forms. This technique does not allow great elevation of the areola (no more than 4–5 cm), but it is good and safe for correcting minor to moderate ptosis combined with volume augmentation.     

聚丙烯酸胺水凝胶注射隆乳并发症处理方法的探讨

目的探讨聚丙烯酞胺水凝胶注射隆乳术后并发症处理方法。方法对28例聚丙烯酸胺水凝胶注射隆乳者,采用显露抽吸、刮除、部分腺体及肌肉切除等方法,清除其注射物,消除并发症。结果所有病例症状较术前有明显好转,效果满意。结论手术切开是处理聚丙烯酸胺水凝胶并发症较合理的方法,可以最大程度取出注射物。     

Anatomy of superficial thoracic artery related to subpectoral augmentation mammoplasty

The aim of this study is to elucidate the anatomic details of superficial thoracic artery related to transaxillary subpectoral augmentation mammoplasty.Thirty-three breasts of Korean cadavers (11 males, 6 females) were dissected. The superficial thoracic artery was found at the lateral part of the pectoralis (P.) major muscle in all cases. It originated mostly from the lateral thoracic artery (42%), thoracoacromial artery (38%), and partly from axillary artery (19%). Most of (82%) the muscle entering point was included in the circle of 2.5-cm radius. The center was located 2.5 cm superior from the intersection of the lateral border of the P. major and inferior border of the fourth rib. It was distant from 12 cm lateral to the midline and 6 cm below the sternal notch.We think that the superficial thoracic artery might be the culprit of bleeding and severe hematoma in transaxillary subpectoral mammoplasty.     

The management of severe capsular contractures following breast augmentation

Several patients with severe capsular contracture following conventional augmentation mammoplasty with subcutaneously placed implants have had substantial improvement by replacing the implants in a submuscular position.