Breast Implant Placement

Breast Implant PlacementBreast implants can be placed in either the subglandular or the submuscular plane. In general, breast implant doctor Stuart Linder most commonly performs submuscular or the dual plane technique. Dual plane technique refers to placing the implant two-thirds under the muscle medially and one-third above the muscle along the lateral third of the breast.

The implants are placed subpectorally in order to:

1) reduce visibility and palpability
2) reduce encapsulation and scar tissue
3) enhance the radiologist's technique during mammography to detect breast cancer
4) maintain a more natural appearance to the breast
5) help elevate and maintain the shape of the implant by reducing skin laxity and gravitation, or inferior descent.

In a majority of patients, Dr. Linder will perform subpectoral dual plane technique; however, there are cases with subglandular technique and these include:

1) thick chested women with very thick muscles and glandular tissue in which placing the implant behind the muscle would reduce the fullness of the implant. These are women with larger than a full D or C-size breasts
2) tubular breast deformities on occasion

These women will do well with subglandular if there is very thick breast tissue and the patient has minimal upper pole fullness.

Placing the implant using the dual plane technique usually requires releasing the parasternal and the lateral inframammary attachments of the pectoralis major muscle, in order for the implant to descend to a proper position. Dr. Linder sees a significant number of patients every year with double-bubble deformities where the implants were not lowered appropriately from the original surgery because the muscles were not accurately released. As a result, the revision surgery requires a capsule to be removed and the muscle is appropriately released so that the implant can settle to its normal position. We refer to this as a "catcher's mitt syndrome." Every time the implant muscle is contracted, the muscle which was not appropriately released pushes the implant superiorly, which thereby leads to consistent superior retroposition of the implant and a double-bubble deformity.

The incision sites can include periareolar, transaxillary, inframammary, or transumbilical. We do not perform transumbilical at any time. In my hands at least, I believe that this is not a reproducibly successful operation, because the distance from the umbilicus to the chest wall is so great that absolute precise dissection is more difficult to perform. Transaxillary can also be difficult, and a significant number of these patients who have this incision are seen monthly by Dr. Linder for a revision. When the implants are inserted through the armpits, they can be positioned in an improper place, which can cause malpositioning and superiorly retropositioned, where the folds are not accurately released. This is especially seen in patients with preoperative ptosis or skin laxity. As a result, we do not perform transaxillary. Placement DiagramThe inframammary approach is considered an acceptable manner, or "gold standard" to place the implants. We do not perform that usually as well when we're working from inferior to superior backwards. It seems to be most predictable, easier, and functional to centralize the implant using the periareolar approach. Using the periareolar approach has many favorable aspects:

1) I am working directly around the breast as a bull's eye. The implant can be positioned perfectly, the release of the muscle is consistent both along the parasternal and the cleavage area, and positioning of the implant is easier.
2) It's easy to detect the nerve, the fourth lateral intercostal nerve along the lateral breast, between the 4th and 5th ribs, along the serratus anterior muscle and the pectoralis major. It's very easy to visualize, thereby reducing numbness to the nipple areolar complex. The periareolar approach will also allow for hemostasis easily, in which the blood vessels can be identified both along the medial parasternal area from the internal mammary perforators as well as laterally along the lateral thoracic branches, which can be coagulated or ligated successfully - reducing blood loss.

Breast augmentation is typically performed under general anesthesia with Board Certified Anesthesiologists only. Laryngeal Mask Airways are normally used; however, patients with reflux, aspiration, or history of gastritis will undergo general endotracheal tube intubation. All patients are normally given preoperative intravenous antibiotics, such as Cephazolin, or patients with penicillin allergies can be given ciprofloxacin or vancomycin (if prescribed by the infectious disease specialist). Additionally, all patients are given pneumatic boots to the lower extremity and to reduce the incidence of deep venous thrombosis. Patients are taken off of all estrogen products and oral contraceptives for at least seven days prior to surgery to reduce DVTs and pulmonary emboli. Smoking should also be ceased two weeks prior to surgery. Blood work is obtained from all patients preoperatively, including CBC, PT/PTT, HIV, and Beta HCG. Also, 12-lead EKGs and chest X-rays are needed from all patients over the age of 40. Mammograms are required for all patients over the age of 35, or have a family history of breast cancer.

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Beverly Hills OfficeStuart A. Linder, M.D., F.A.C.S., Inc.

Phone: (310) 275-4513
Fax: (310) 275-4813
9675 Brighton Way, Suite 420 Beverly Hills, CA 90210

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