¡g and glandular tissue are unfavorable and too thin: if the implants were

00 incorporated above the muscle, the skin covering would be too thin and rippling and the impression of an implant would be inevitable. In this case the implant must go underneath the muscle. It cannot be said that one method is better than the other; the operating surgeon should, based on his or her experience, decide in each individual case whether the implant should be placed above or below the muscle.

A submuscular implant is appropriate if the following conditions exist:

• Glandular hypoplasia, with thin covering of soft tissue

• Postpartum involution atrophy with moderate surplus of thin soft tissue

• Glandular aplasia

• Previous subcutaneous mastectomy

• Recurrent capsular fibrosis

• Pressure atrophy of the breast where an implant is already in place

In over two-thirds of the cases it will be fine to position the implant above the muscle. This is why there is more detail about this method in the manual.

■ If the implant is positioned underneath the muscle, then the points of attachment of pectoralis major are detached along the rib from the intermediate area medially in the direction of the sternum, where one should always ensure that there is a distance of 3 cm or two fingers from the right to the left breast between the two implant pockets. The implant pockets must not communicate.

■ The dissection may be carried out using a scalpel or Metzenbaum scissors. It is recommended, however, that the electric scalpel be used since this produces less bleeding. One should always use the rib for orientation. When carrying out the dissection, one should ensure that no perforations are produced in the intercostal spaces.

A good light source is required for submuscular dissection, so that one can also stop bleeding in the deeper regions without difficulty.

Layers The Intercostals Netter

■ Like the supramuscular access, the beginning of the dissection is very important, as this is when the correct layer is demonstrated. Then, even when carrying out dissection under the muscle, much of the detachment can be carried out using the middle or index finger as a blunt instrument. In the medial and caudal part it may be necessary to cut through the connective tissue and strong muscle fibers using a sharp instrument, either with Metzenbaum scissors or the electric scalpel. If the electric scalpel is used, care must be taken to avoid perforations.

•2 This diagram illustrates how the pectoralis major is inserted on the fQ

sternum caudally. This part of the insertion, depicted with the dotted E line, is detached up to the height of the nipple using scissors or the elec-

¿g tric scalpel. The process of completely cutting through it can be mom

's tored using the adipose tissue behind as a guide, as this will become

£ visible because the muscle retracts. Meticulous hemostasis must be

carried out twice in order to avoid postoperative bleeding, which always occurs during the first 24 h.

These two figures show the position of the implant underneath the muscle and above the muscle, respectively. One can see that as a result of the traction and fitting of the implant, the muscle retracts after being detached and this ensures good coverage over two-thirds of the implant.

The three-layer wound closure is the same for both access methods. The concealed fixation suture of the muscle fascia with 2.0 Monocryl is important since this ensures that the inframammary fold is defined and a stable counter-position to the implant is created.

Before the operation - frontal view
Before the operation - semioblique view, right

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