隆乳术切口和假体置放层次及手术剥离范围探讨

目的：探讨隆乳术的切口选择、假体置放层次和腔穴剥离范围。方法：于1996例9月至2001年9月间行隆乳术537例，选择三种手术切口；乳房下皱襞切口、乳晕切口、腋窝切口；假体置放于乳腺后间隙或胸大肌后间隙；胸大肌后间隙的剥离范围以第6肋间隙为下界。术后随访半年-5年。结果：术后乳房位置、形态、手感均满意511例（占95.2%）。结论：乳房下皱襞切口适于站立时乳房下皱襞明显或者乳房轻度下垂者；对于乳晕直径≥4cm的受术者，可采用乳晕缘内上或者内下弧形切口；腋下切口最为隐蔽，适于所有的受术者。假体置放于胸大肌后间隙具有手感更真实、不易形成纤维囊性硬变、不影响哺乳等优势。在胸大肌后间隙进行剥离，顺应乳房下皱襞韧带的解剖结构，将下界定于第6肋间隙。     

Complete Submuscular Breast Augmentation: 650 Cases Managed Using an Alternative Surgical Technique

Background An alternative complete submuscular surgical technique for primary breast augmentation is presented. Since 1998, the author has refined the procedure for total submuscular placement of textured silicone gel implants, with good results for more than 650 patients. Methods The submuscular plane is accessed via a semicircular periareolar incision. Round or anatomic implants are placed beneath the pectoralis major and external oblique muscles, the rectus sheath, and the serratus anterior muscle fascia, which together create a contiguous structure that completely separates the implant from the breast tissue. Results High-riding implants were the main complication in early cases, through creation of an insufficiently large submuscular pocket. Only a very low incidence of Baker II capsular fibrosis was observed, and there were no Baker III or IV capsular contracture revisions. There were no cases of infection or “bottoming out.” Areolar scarring was well concealed, and rippling and implant distortion were virtually nonexistent. Even in thin women, the implant edge was scarcely visible or palpable. Patient satisfaction levels were very high, with the majority viewing the implants as their own tissue in terms of natural feel and appearance. Conclusions The advantages of the described surgical method are several-fold, particularly for lean patients. It offers a promising alternative to subglandular and partial submuscular implant placement and to other total submuscular techniques for primary breast augmentation. Furthermore, it provides a solution for tuberous and ptotic breasts, coupled with mastopexy as required, and good results have been achieved with correctional surgery for subglandular capsular contracture, bottoming out, and rippling.     

Augmentation Mammoplasty: Personal Evolution of the Concepts Looking for an Ideal Technique

The purpose of this paper is to report our personal experience in the field of augmentation mammoplasty. This experience is based on over 15 years in practice and working with more than 400 cases using different types of prostheses (single-lumen gel-filled, single-lumen saline-filled, double-lumen, smooth or texturized surfaces), different routes (submammary, periareolar, transaxillary), and different locations of the implant (complete submuscular, subglandular, subpectoral). Our present preference is for a partial submuscular (subpectoral) augmentation mammoplasty through an inferior periareolar route. The results of 91 consecutive patients operated on with this technique from January, 1990 to December, 1994, during the blow-up of the controversy on silicone, are reported.     

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。     

Muscle-Splitting Breast Augmentation: A New Pocket in a Different Plane

Background Breast augmentation usually is performed in subglandular, subfascial, or partial submuscular pockets, including the dual plane. A new pocket has been described and used by the author. The initial pocket was made in the subglandular plane up to the lower level of the nipple–areolar complex, and the submuscular plane was reached by splitting the pectoralis major muscle without its release from the costal margin. The implant lies in this plane simultaneously behind and in front of the pectoralis. Methods From October 2005 to November 2006, 125 patients underwent bilateral breast augmentation using the new technique. Soft cohesive gel microtextured round implants ranging in size from 230 to 440 ml were used. Results All the patients experienced a quick recovery with three-dimensional enhancement and having the benefits of both subglandular and submuscular planes. No rippling, lateral displacement, double-bubble deformity, or muscle contraction–associated deformities were seen. All the patients had aesthetically natural cleavage, with the nipple at the most projected part of the breast. Postoperative analgesia requirements were reduced because of dissection in natural planes. Conclusion For adequate cover of the prosthesis, only the upper part of the pectoralis major muscle is required. This can be achieved by using the pectoralis muscle-splitting technique. The pectoralis major was split in the direction of its fibers, avoiding extensive muscle release. Surgical morbidity was reduced, resulting in a quick postoperative recovery and a more natural three-dimensional appearance of the breast. Oral presentation at the 6th Croatian Congress of Plastic, Reconstructive, and Aesthetic Surgery, Optija–Rijeka, Croatia, 6–11 October 2006     

A new implant methodology for the patient with a small nipple-areolar complex diameter

Background: Both the conventional periareolar approach and the inframammary approach present difficulties in breast augmentation when treating the patient with a small nipple-areolar complex diameter. Objective: We describe an approach that uses a 360-degree periareolar incision. Methods: A ring of skin was demarcated around the areola by outlining 2 concentric circles. The epidermis between the rings was removed. The deep dermis was cut in a ring, with the 3- and 9-o'clock positions of the outer circle being the start and finish of the approach, until the subglandular or submuscular plane on the outside of the inferior external edge of the pectoralis muscle was reached, thus developing the pocket. After implant placement, primary closure was accomplished by using 3-0 nylon purse-string sutures and 5-0 nylon dermal interrupted sutures. Results: The procedure was successful in a series of 23 patients treated between January 1992 and July 2000. Conclusions: This approach provides an adequate surgical field with an excellent view of the surgical pocket and easy management of hemostasis, and it permits placement of the implant without damage to the device or the skin margins. (Aesthetic Surg J 2001;21:320-327.)     

Augmentation Mastopexy in Muscle-Splitting Biplane: Outcome of First 44 Consecutive Cases of Mastopexies in a New Pocket

Background  

Augmentation with mastopexy is a commonly performed procedure and is done either simultaneously or in stages. The augmentation component can be accomplished by placing an implant in the subglandular, partial submuscular, or subfascial plane, and mastopexy can be performed using periareolar, vertical, or Wise pattern markings. These two components are independent of each other and any pocket can be combined with suitable external markings. The muscle-splitting submuscular biplane is a new pocket and is combined with conventional envelope reductions for mastopexy.     

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.     

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     

Immediate breast reconstruction with anatomical permanent expandable implants after skin-sparing mastectomy: aesthetic and technical refinements

Use of anatomic permanent expandable implant after skin-sparing mastectomy (SSM) permits a 1-stage immediate breast reconstruction with an optimum breast shape. Preservation of most of the mammary skin after SSM on 1 side and anatomic prosthesis shape on the other makes breast reconstruction easier and enhances the quality of the esthetic results. The authors describe their experience with 40 immediate breast reconstructions after SSM performed over a period of 2 years explaining some technical details. The implant is placed in a submuscular pocket, or preferably, depending upon the condition of the muscles and skin flaps after mastectomy, in a submuscular-subfascial pocket. In this case, the undermining of the pocket is submuscular in its upper part under the major pectoralis muscle and subfascial in the lower part of the breast undermining the adipo-fascial tissues above the anterior serratus muscle. The submuscular dissection is done in continuity with the subfascial dissection to allow the complete closure of the soft tissues over the implant. In this case, the minor consistency of subfascial tissues compared with muscle in the inferior pole of the breast allows the easier and quicker distention of the soft tissue overlying the prosthesis during the inflation phase and ensures a good shape of the breast soon after surgery. Whenever possible, the mastectomy is performed through a periareolar skin incision that is closed with a purse-string suture. Finally, the authors discuss the indications of 2 different-shaped anatomic permanent expandable implants: full-height and short-height prostheses with different shape and fullness of the upper pole of the implant.     

Anatomic and Physiologic Advantages of Totally Subfacial Breast Implants

For the past 4 years, whenever it was possible to choose between the subglandular or the submuscular location for the implant pocket (in cases with no precise indication for the submuscular location), the authors have opted for the totally subfascial plane (subaponeurotic) to avoid the disadvantages of the other locations and to obtain additional benefits. The subfascial plane lies below the deep thoracic fascia, or deep aponeurosis, which is not only that of the pectoralis (the muscle connecting with the breast in its upper two-thirds only). The implant is placed completely beneath this fascia, which covers, in addition to the pectoralis major muscle, the serratus, the lateral oblique, and the rectus anterior muscles. This study included 100 women who had breast implanted in the subfascial (subaponeurotic) plane. Of these women, 63 were thin patients with little fatty tissue. Textured surface implants were used McGhan style 120 and 110. All procedures were approached through an inferior periareolar incision. Excellent coverage of the implant as well as natural shape and mobility was achieved for all patients. No rippling in the upper half was observed. Two patients had Baker grade 2 capsular contracture (2%). No seromas or infections were seen, and only once was a surgical exploration necessary for excess drainage volume (1%). In the immediate postoperative period, less edema was recorded and recovery was faster than with the other two procedures: submuscular and subglandular. When circumstances indicate a subglandular pocket, the subfascial plane would seem to be the logical place for mammary implants.     

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.     

Transaxillary subfascial breast augmentation

The author's view is that transaxillary subfascial breast augmentation provides consistent, satisfactory results with ease of dissection. Compared with submuscular placement, this technique involves less risk of hematoma, less pain, and faster recovery, and injury to the intercostobrachial nerve is less likely. Also, there is no change of implant shape with muscle contracture. (Aesthetic Surg J 2003;23:480-483)     

经乳头根部小切口盐水假体隆乳术-30例临床回顾

目的：选择合适的皮肤切口入路，操作方便，组织损伤小，术后瘢痕不明显是未来隆乳术的发展方向。基于这一原则，笔者选择经乳头根部小切口行盐水假体隆乳术，旨在观察术后的效果。方法：全麻或局麻下，于乳头下侧缘距基底部2mm处设计半环形切口。对于乳头过小者，可向两侧乳晕水平方向延长5mm，总长度小于2．5cm。沿此切口切开皮肤全层，沿乳腺导管走行方向分离，在乳腺下或胸大肌下制造腔穴，将充注式盐水袋假体置入腔穴。再将200ml～300ml盐水通过阀门注入。观察双侧乳房大小、形状、对称性均满意后分层缝合和包扎。结果：从2000年1月～2007年12月，我们用此种方法行隆乳术30例。术后早期5例患者出现乳头感觉暂时减退，1～3月后均恢复正常。10例乳房表面出现局部轻微褶皱塌瘪，2例假体破裂，取出后再次置入新假体。无乳头畸形、包膜挛缩、双侧不对称，所有患者对切口瘢痕感到满意。结论：经乳头根部小切口置入盐水充注式假体手术，操作简便，安全性高，损伤乳腺组织少，愈后切口瘢痕隐蔽。该术式是可行的，值得在临床上推广应用。     

经乳晕上切口矫正轻度下垂乳房的隆乳术

目的　一次性完成隆乳并矫正乳房轻度下垂。方法　经乳晕上切口切除半月形皮肤 ,不切开乳腺置入乳房假体 ,将乳腺组织上移悬吊固定于胸大肌深筋膜。结果　 2 3例乳房轻度下垂的小乳症患者术后乳房及乳头形态位置良好 ,乳晕切口瘢痕不明显 ,乳头感觉及勃起正常。结论　该方法隆乳同时矫正下垂乳房效果可靠稳定 ,创伤小 ,止血彻底 ,瘢痕不明显。     

Combining muscle-splitting biplane with multilayer capsulorrhaphy for the correction of bottoming down following subglandular augmentation

Implant malplacement is the second most common reason for revision and bottoming down is the most common presentation of implant malplacement. Submuscular biplane relocation was combined with capsulotomies and multilayer capsulorrhaphy when bottoming down was seen following subglandular breast augmentation. Between 2005 and 2009, bottoming down following subglandular mammoplasty was seen in 41 breasts (19 bilateral and three unilateral). Of the 19 patients, 12 had downward transgression of inframammary crease (IMC) alone; this also included a patient with vertical scar mastopexy. Two patients had multiplane malplacements where bottoming down was associated with lateral displacement (telemastia) in one and medial displacement (symmastia) in the other. Two had simultaneous downward transgression of the IMC and nipple areolar complex (NAC) and three had bottoming down with capsular contracture independent of NAC descent. Follow-up of up to 3 1/2 years showed stable IMC and NAC relationship with acceptable results. Dog ear revision was required in one patient when IMC relocation was accompanied with vertical scar mastopexy and one patient needed revision for further relocation and improvement of symmastia. No wound breakdown or periprosthetic infection was seen in their series. Multilayer capsulorrhaphy with submuscular biplane repositioning of implants is a suitable option to correct bottoming down following subglandular augmentation.     

A meta-analysis of optimum plane placement and related morbidity in primary breast augmentation

Despite extensive clinical experience of breast implants, there is continued controversy regarding the optimum placement of the prosthesis. More importantly, there is insufficient data to accurately determine whether subglandular (SG) or submuscular (SM) placement of the prosthesis diminishes postoperative complications. A search of published trials (n = 34) examined complication rates following SG and SM implant placement was conducted. Pubmed (MEDLINE) database was used and the available data was then cross-referenced. Eligible trials (n = 6) were then reviewed and selected data extracted. Primary outcomes measured were postoperative haematoma, infection, capsular contracture and implant migration. 3603 patients were identified from relevant trials examining postoperative complication rates for both subglandular and submuscular implant planes. The submuscular implant plane was associated with a higher incidence of postoperative haematoma (OR 2.87, 95% CI, 1.44-6.11). The incidence of capsular contracture (OR 4.77) is more common when a subglandular plane is used. No significant difference was noted in the rate of postoperative infection (OR 1.20, 95% CI 0.57-2.58) or implant migration (OR 1.56, 95%CI 0.12-87.4) between the two groups. This meta-analysis confirms that subglandular augmentation results in lower short-term morbidity; however, submuscular placement appears to provide the best long-term outcome in terms of morbidity. In the absence of randomized controlled trials comparing these two techniques, this meta-analysis provides evidence to guide surgeons to achieve the best outcomes for their patients.     

Endoscopic Transaxillary Subglandular Breast Augmentation Using Silicone Gel Textured Implants

We present our experience with endoscopic transaxillary subglandular breast augmentation using textured silicon gel implants. Fourteen implants were placed in seven patients through a 4 cm axillary incision, in a subglandular pocket, with the help of a 10 mm, 30° endoscope with a subcutaneous retractor and endoscopic diathermy. The implant was inserted with the help of a plastic bag. No drains were left in place. The duration of the procedure was 1 h 30 min in the most recent cases. Bleeding during surgery was kept to a minimum, and there were no complications such as capsular contracture, hematoma, or hypertrophic scar. Infection occurred in one implant and it was necessary to extract it. This technique is an excellent tool for patients requiring subglandular implants who prefer a distant incision. It provides good control over dissection and allows the use of silicone gel implants, thus avoiding the risk of deflation. In addition, recovery is faster and there is less bruising and pain.     

Preliminary (3 years) experience with smooth wall silicone gel implants for primary breast augmentation

The goal of this study is to obtain data concerning the incidence of capsular contracture and reoperation rates in patients having primary breast augmentation utilizing modern low-bleed smooth-wall silicone gel implants. Data were collected retrospectively and consisted of 44 patients who underwent primary breast augmentation using smooth silicone gel implants (Mentor Corporation) in the period between 2001 and 2003. Of the 131 patients identified, 44 patients fit the criteria of primary breast augmentation. Secondary cases and primary augmentation with mastopexy were excluded from this study. This group of patients is still followed, and the data are being updated periodically. A total of 44 patients underwent primary breast augmentation. Average age was 32 years (range, 19-57). Average follow-up was 34 months (range, 28-40). Average operative time was 52 minutes. The inframammary incision was used in 65% of patients and the areolar incision in 35%. The subglandular position was used in 35% of patients versus the submuscular position in 65%. Nine patients (20%) developed capsular contracture. Six patients (13.6%) had Baker 3 capsular contracture, which required revision. Four of the 9 patients with capsular contracture had implants placed in the submuscular space and 5 in the subglandular position. Relative to the implant position, 4 patients (9%) with implants placed in the submuscular position developed capsular contracture. Relative to the subglandular position, 5 patients (11.3%) with implants placed in the subglandular position developed capsular contracture. Eight patients (19%) required implant revision, 6 patients for capsular contracture, and 2 patients requested size change. Preliminary data from this study indicate that the use of the new generation of gel implants yields less capsular contracture, as well as decreased revision rates. Subglandular placement of gel implants did not significantly increase the risk of capsular contracture. Longer follow-up and multicenter studies are still needed to confirm these findings. This cumulative data could challenge the current status of gel implant moratorium imposed by the incidence of capsular contracture and revision rates.     

Striae Distensae After Subfascial Breast Augmentation

Striae distensae or stretch marks after breast augmentation are a rare complication. To date, 10 cases have been published. In seven of these cases, the implant was placed in a subglandular position and in the other three cases, placement was submuscular. Two cases of stretch marks in two young nulliparous women who underwent subfacial breast augmentation are presented. To the best of the authors’ knowledge, this is the first report of striae distensae after subfascial breast augmentation.