Paramammary Lymph Nodes

Since the beginning of humanity the female breast has been synonymous with the idea of femininity. The "ideal" size, however, always depended on whatever was in vogue at the time, and any appropriate changes were made on illustrations. The first references to surgical interventions to increase the size of the female breast date back to the end of the nineteenth century. There are reports of treatments ranging from fat transplants to paraffin injections, from creams and various synthetic materials to silicone injections, and, as one can imagine, these had disastrous consequences. It was not until the 1960s that it became possible to develop usable silicone gel implants. The further development of these has continued until the present day and has given rise to a safe method of breast augmentation. This is due above all to the viscosity of silicone gel, which enables the implant to be as natural as possible. There are also saline-filled implants on the market, but these have inherent disadvantages. The saline can diffuse more easily through the outer silicone layer, which firstly may produce a loss and unevenness in size, and secondly may give rise to noises.

The advantages of titanium-coated hydrogel breast implants and others need to be demonstrated in long-term studies. For decades we have been using roughened implants with silicone gel (INAMED Aesthetics, Santa Barbara, CA; Düsseldorf, Germany [formerly McGhan Medical]) without complications and with a low capsular fibrosis rate.

Breast enlargement is a very frequently desired operation. This book presents the most simple, clear technique in order to ensure that the novice has a basic idea of how to introduce breast implants and to avoid risks. The simplest, safest access is by means of a 3- to 4-cm-long incision in the inframammary fold which, if it is made precisely, if an atraumatic suture technique is used and if there is good postoperative treatment, is hardly visible after 3 months.

The access described in the manual is very clear and easily understandable and also produces good aesthetic results. Of course, a breast implant may also be introduced via the nipple and via the axilla. This requires the person carrying out the operation to have appropriate experience. In some cases it will be indicated. Any breast implant, however, may be introduced without any problems by means of the access described in the manual. It is then up to the young aesthetic surgeon to build on this knowledge.

•2 Once the question of access has been resolved, the second-most-impor-

tant decision is whether the implant is going to be placed above the pec-£ toralis major or underneath it. Here, too, the manual gives clear and easily

¿g understood instructions, namely, that generally, if there is good skin and

"K gland coverage, the implant is positioned above the muscle, between

^ muscle and gland. The operation is carried out macroscopically and the dissected pocket is monitored by means of an endoscope so that any bleeding is seen, all strands of connective tissue are cleanly cut through, and the implant pocket is prepared in an anatomically clean manner.

In a clinical study of 500 patients followed up at the Bodenseeklinik, the fibrosis rate was not significantly lower with submuscular access than with supramuscular access (<4%).

Submuscular access is and must be carried out if, following pregnancy or dramatic weight loss, only a very thin flap of ptotic skin is present, meaning that the covering is very weak. Otherwise an impression of the implant and a rippling phenomenon is unavoidable. In this case the implant must be placed under the muscle. This intervention is more laborious and causes more bleeding. The pectoralis major must be separated while in view, including by endoscope, at its lower margin up to the midline using an electric scalpel, cutting through its points of attachment on the relevant costal arches, directly from the rib. Subsequently, the muscular pocket can generally be dissected bluntly. A disadvantage of this method may be that the implant slips and that the muscle contracts and changes, which means that when the implant is in the submus-cular position, there may be later cosmetic problems and changes if the submuscular pocket is not dissected completely cleanly.

Consequently, a novice in the area of aesthetic breast surgery should send patients who have difficult skin and ptotic breasts to an experienced breast surgeon. As a novice, one does not do oneself any favors by carrying out complicated breast operations. In this book, therefore, we have only selected subglandular breast implants with access via the inframammary fold since this intervention can be easily learned, is standardized, and is associated with low risk.

When implants are used, these should only be implants that have been licensed by the health authorities. Similarly, to start with one should not use implants that are too large (not over 350 g) since these are associated with significantly more postoperative complications and a significantly greater desire for subsequent operations than is the case of smaller implants.

Breast Implants .2

Every day, women in Germany fulfill their dreams of having well-formed «

breasts. While the round shapes - which are obviously implants - are w still preferred in the USA, German women want their surgically enlarged ^

s breasts to have a natural appearance: the 'tear shape'. Yet, it is not only 2

important to have a natural appearance; the implanted material should m also feel as natural as possible. Tear-shaped implants are made entirely of silicone - with good reason. Other materials used for breast implants have proved to be extremely disadvantageous for patients. Sodium chloride is certainly safe as regards patients' health but it has drawbacks: the implants gurgle and the material has nothing in common with the surrounding breast tissue. For this reason, only McGhan silicone gel breast implants from Inamed Aesthetics* are used at Professor Mang's Bodenseeklinik. As the sole manufacturer, Inamed Aesthetics has experience with these implants stretching back more than 25 years. This is an important point as the quality and safety of the implant play an important role in the result of the breast operation. Publications throughout the world confirm the fact that these implants have the lowest complication rate, which is in line with the high quality and safety requirements at the Bodenseeklinik.

A standardized quality mark for breast implants has been in existence throughout the entire European Union for three years. This guarantees that the implants will not harm patients' health. The silicone implants used today are filled with cross-linked (cohesive) silicone and therefore cannot leak. If such an implant is cut open, the contents appear as firm as a wine gum. The surface has also been made rough which ensures that the implant meets completely naturally with the tissue. Inamed Aesthetics guarantees the safety of the implants with the INAMEDPlus guarantee program.

This program covers every McGhan silicone gel breast implant which has been explanted due to unexplained damage to the implant shell and the resultant rupture of the shell. The decisive factor is that it was implanted after March 31 2004.** Even in such highly unusual cases,

* Inamed Aesthetics GmbH, Hansa-Allee 201,40549 Düsseldorf, Germany.

** Breast implants which were used before 31 March 2004 come under the Inamed Aesthetics Standard Product Exchange Program. Inamed Plus is offered in addition to the Inamed Aesthetics Standard Product Exchange Program. This represents a new era in breast surgery and will make many patients feel safer. From June 2004 the company Inamed issues a life-long guarantee for breast implants.

•2 only a cosmetic correction is required - the patient's health has not been fQ

put at risk because of this at any time. If the explanted product is no £ longer being produced, it will be replaced by a current and equivalent

^ breast implant. And what is more, patients affected by this will receive

"K a financial contribution of up to 1,000 Euro for explantation required

^ as a result of damage to the implant shell, as long as this is carried out within 10 years after implantation. More detailed information on this exclusive guarantee program can be obtained directly from the Bodenseeklinik on request.

Inframammary Lymph Node

Anatomical Overview

1. Infraclavicular lymph nodes

2. Cervical plexus

3. Parasternal lymph nodes

5. Pectoral fascia

6. Submammary lymph nodes

7. Superior epigastric artery

9. Intercostal arteries

11. Thoracodorsal artery

12. Areola

13. Nipple

14. Paramammary lymph nodes

15. Breast

16. Lateral thoracic artery

17. Internal mammary artery

18. Axillary lymph nodes

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