PRIMARY BREAST AUGMENTATION

Nina S. Naidu, MD, FACS

Philosophy and Goals

• to create a natural-appearing breast which fills the patient’s tissues adequately

• to minimize the risk of complications which can result from placing a medical device into a patient for cosmetic reasons

• to improve the body image and self-esteem of the patient

Initial telephone call/internet inquiry

Goal: to get the patient into the office• Respond to patient’s call/email immediately• Send written information about procedure • Initial consultation scheduled: 45-60 minutes• Second consultation scheduled if patient

wishes to proceed with surgery: 45 minutes for photos, implant sizing, paperwork, additional questions

Initial Consultation

1. Brief history of breast augmentation• Do implants cause disease: breast cancer,

connective tissue diseases, interference with mammography

• Breast implant technology: saline vs silicone• History of silicone moratorium

Initial consultation (con’t.)

2. Summarize the alternatives• incision: infra-mammary, peri-areolar, trans-axillary• location: subglandular vs subpectoral• implant type: silicone vs saline, smooth vs textured, round vs anatomic• size: do not guarantee a cup size!

Pre-operative planning

• Goal: to have a clear surgical plan prior to surgery-eliminates the need to use sizers-eliminates second-guessing on the OR table-decreases operative time-provides more predictable results

Preoperative planning: High Five Tissue Analysis (Tebbetts)

1. Implant coverage: select a pocket location which will optimize soft tissue coverage

2. Implant volume: select implant volume to produce optimal envelope fill (TEPID™)

3. Implant dimensions and type: selecting specific implant characteristics

4. Infra-mammary fold location: estimate desired postoperative infra-mammary fold position

5. Incision location: select desired incision location

1. Implant coverage (pocket location)

• 1. subglandular: – implant is exposed to breast

tissue – soft tissue coverage is

decreased– less risk of implant distortion

• 2. subfascial: – above muscle to avoid muscle

distortion – fascia provides additional

layer of coverage of implant – Graf, Plast Reconstr Surg

2003; 111: 904-908.

1. Implant coverage (pocket location)

• 3. subpectoral:– complete muscular coverage of implant – protection from breast bacteria– possible implant displacement from muscle– decreased incidence of capsular contracture

(Vazquez, Aesthet Plast Surg 1987; 11: 101-105)

• 4. dual-plane: partial subpectoral placement– I: divide muscle across IMF– II: divide muscle and separate overlying

parenchyma up to inferior border of NAC– III: divide muscle, separate parenchyma up to

nipple or superior border of NAC– Tebbetts: Plast Reconstr Surg 2001; 107: 1255-

1272.

Dual-plane breast augmentation (Tebbetts)

2. Implant volume

TEPID™ System measurements– BW: base width of existing breast parenchyma– APSS: anterior pull skin stretch– STPTUP: soft tissue pinch thickness of upper pole– STPTIMF: soft tissue pinch thickness at IMF– N-IMF: nipple-inframammary fold distance under

maximal stretch– PCSEF: parenchyma’s contribution to stretched

envelope fill

Pre-operative measurements (Tebbetts: Plast Reconstr Surg 2005; 116: 2005-2016)

Base Width APSS (anterior pull skin stretch)

Pre-operative measurements(Tebbetts: Plast Reconstr Surg 2005; 116: 2005-2016)

STPTUP & STPTIMF N-IMF

Pre-operative measurements (Tebbetts: Plast Reconstr Surg 2005; 116: 2005-2016)

PCSEF (parenchyma contribution to stretched envelope fill)

Determining the optimal size: TEPID™ system

Base width (cm)

Base width parenchyma (cm)

10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0

Estimated initial implant volume (cc)

200 250 275 300 300 325 350 375 375 400

APSS If APSS < 2.0, -30 cc

STPTUP If APSS > 3.0, +30 cc

STPTIMF If APSS > 4.0, +60 cc

N:IMF If N:IMF > 9.5, + 30 cc

PCSEF If PCSEF < 20%, +30 ccIf PCSEF > 80%, -30 ccEstimated implant volumeFor each volume indicated

200 250 275 300 325 350 375 400

Set new IMF at N:IMF (cm)

7.0 7.0 7.5 8 8 8.5 9.0 9.5

3. Implant dimensions and type

• a. shape: round versus anatomic-no difference in shape with round vs anatomic implants in upright position (Hamas, Aesthetic Surg J 1999; 19: 369-374)

• b. profile: low versus medium versus high-potential negative effects of high and extra-high profile implants (Tebbetts, Plast Reconstr Surg 2010; 126: 2150-2159)

3. Implant dimensions and typec. fill: silicone vs saline

– more natural feel of silicone; lower rates of rupture, asymmetry, malposition (Spear, Aesthetic Surg J 2010; 30: 557-570)

d. surface: textured vs smooth-no difference in rate of capsular contracture b/t textured and smooth implants when placed in the submuscular position (Kjoller 2001, Ann Plast Surg 47: 359-366)

4. Infra-mammary fold locationBase width (cm)

Base width parenchyma (cm)

10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0

Estimated initial implant volume (cc)

200 250 275 300 300 325 350 375 375 400

APSS If APSS < 2.0, -30 cc

STPTUP If APSS > 3.0, +30 cc

STPTIMF If APSS > 4.0, +60 cc

N:IMF If N:IMF > 9.5, + 30 cc

PCSEF If PCSEF < 20%, +30 ccIf PCSEF > 80%, -30 ccEstimated implant volumeFor each volume indicated

200 250 275 300 325 350 375 400

Set new IMF at N:IMF (cm)

7.0 7.0 7.5 8 8 8.5 9.0 9.5

5. Incision location• 1. infra-mammary: excellent

visualization and control; decreased incidence of capsular contracture (Wiener, Aesthet Plast Surg 2008; 32: 303-306)

• 2. peri-areolar: very good exposure, but more exposure of implant to endogenous breast bacteria

• 3. trans-axillary: good visualization with endoscope; limited to smaller gel implants

• 4. trans-umbilical: blind dissection; limited to saline implants

Pre-operative markings1) Mark midline2) Mark medial

perforators 1.5 cm off midline

3) Mark current IMF4) Mark new IMF5) Mark incision (4-5 cm)

Operative sequence

Goals: minimize blood loss, work efficiently

1. Initial incision and dissection to pectoralis fascia

2. Entering the subpectoral space, leave 1 cm cuff

-lift anteriorly with retractor; the muscle which tents is pectoralis and can now be entered safely

Operative sequence

3. Sequence of pocket dissection-preserve all medial origins of the pectoralis muscle-dissect inferiorly, medial, lateral, supero-lateral, and finally supero-medial

Operative sequence

4. Re-inspection and pocket irrigation-check for hemostasis-triple-antibiotic (cefazolin, gentamycin, Bacitracin)

irrigation (Adams, Plast Reconstr Surg 2006; 117: 30-36)5. Implant placement and positioning

-insert implant, lengthen incision if necessary-run a finger over top and bottom of implant to ensure sitting smoothly without folding

6. Incision closure and dressing-3-0 Monocryl running for fascia -5-0 Monocryl subcuticular for skin-Steri-strips for dressing

Post-operative Care

• Goal: to return patients to regular activity as quickly and as safely as possible– No special bras, no drains, no pain pumps, no

compression dressings– Patients are permitted to shower and perform

most activities that evening, including light lifting– No aerobic activity and no sex for two weeks

Follow-up visits

• 5-6 days postop• 6 weeks• 3 months• 6 months: photos taken• 1 year• Yearly thereafter

KN: 28yo, G0P0, A → full C

KN: pre-operative planningBase width (cm)

R/L Base width parenchyma (cm)

10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0

13/12.5

Estimated initial implant volume (cc)

200 250 275 300 300 325 350 375 375 400

APSS 1/1 If APSS < 2.0, -30 cc -30 -30

STPTUP 1/1 If APSS > 3.0, +30 cc

STPTIMF 1/1 If APSS > 4.0, +60 cc

N:IMF 6/6 If N:IMF > 9.5, + 30 cc

PCSEF If PCSEF < 20%, +30 cc +30 +30

If PCSEF > 80%, -30 cc

Estimated implant volume

300 325

For each volume indicated

200 250 275 300 325 350 375 400

Set new IMF at N:IMF (cm)

7.0 7.0 7.5 8 8 8.5 9.0 9.5

KN: style 15 304 cc smooth round silicone, infra-mammary, dual-plane I

SG: 29 yo, G3P2, B → C

SG: pre-operative planningBase width (cm)

R/L Base width parenchyma (cm)

10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0

13/13

Estimated initial implant volume (cc)

200 250 275 300 300 325 350 375 375 400

APSS 1/1 If APSS < 2.0, -30 cc -30

STPTUP 1/1.5 If APSS > 3.0, +30 cc

STPTIMF 1/1.5 If APSS > 4.0, +60 cc

N:IMF 5.5/6 If N:IMF > 9.5, + 30 cc

PCSEF If PCSEF < 20%, +30 cc

If PCSEF > 80%, -30 cc

Estimated implant volume

295

For each volume indicated

200 250 275 300 325 350 375 400

Set new IMF at N:IMF (cm)

7.0 7.0 7.5 8 8 8.5 9.0 9.5

SG: style 15 286 cc, smooth round silicone, infra-mammary, dual-plane I

PG: 33 yo, G2P2, A → full B

PG: pre-operative planningBase width (cm)

R/L Base width parenchyma (cm)

10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0

12.5/12

Estimated initial implant volume (cc)

200 250 275 300 300 325 350 375 375 400

APSS 1.5/2 If APSS < 2.0, -30 cc -30

STPTUP 1/2 If APSS > 3.0, +30 cc

STPTIMF 2/2 If APSS > 4.0, +60 cc

N:IMF 5/5 If N:IMF > 9.5, + 30 cc

PCSEF If PCSEF < 20%, +30 cc

If PCSEF > 80%, -30 cc

Estimated implant volume

For each volume indicated

200 250 275 300 325 350 375 400

Set new IMF at N:IMF (cm)

7.0 7.0 7.5 8 8 8.5 9.0 9.5

PG: style 15 286 cc, smooth round silicone, infra-mammary, dual-plane I

ES: 37 yo, G3P2, A → C

ES: pre-operative planningBase width (cm)

R/L Base width parenchyma (cm)

10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0

14/14

Estimated initial implant volume (cc)

200 250 275 300 300 325 350 375 375 400

APSS 3/3 If APSS < 2.0, -30 cc

STPTUP 2/2 If APSS > 3.0, +30 cc +30

STPTIMF 2/2 If APSS > 4.0, +60 cc

N:IMF 5/5.5 If N:IMF > 9.5, + 30 cc

PCSEF If PCSEF < 20%, +30 cc

If PCSEF > 80%, -30 cc

Estimated implant volume

405

For each volume indicated

200 250 275 300 325 350 375 400

Set new IMF at N:IMF (cm)

7.0 7.0 7.5 8 8 8.5 9.0 9.5

ES: style 15, 397 cc, smooth round silicone, infra-mammary, dual-plane I

Conclusions

• Have clear goals in mind at every step of the process: consultation, pre-operative, intra-operative, post-operative

• Make sure that you and the patient have the same expectations

• Use a systematic approach that works for you, this will allow you to achieve better and more predictable results

www.naiduplasticsurgery.com

NINA S. NAIDU, MD, FACSPLASTIC & RECONSTRUCTIVE SURGERY

(212) 452.1230