S The operation is performed under general anesthesia achieved with w endotracheal intubation or laryngeal mask ventilation. The day before
2 the operation the doctor carrying out the operation discusses with the
S patient in detail what changes the latter desires and how these can be
00 achieved by the surgeon. The patient must be warned about having unrealistic expectations, and the patient must be informed in detail about postoperative behavior. There should be intra-operative singleshot infection prophylaxis with 2 g cefaclor.
The surgical planning must incorporate information about the skin condition, muscle thickness, a mammogram, or ultrasound of the breast. It must also cover the shape of the chest, the current size of the breast, circumference of the thorax, and the weight and stature of the patient.
A novice in breast augmentation surgery should start with implants that are not too large (no larger than 320 g) and begin by using the safest access. This is access in the inframammary fold (3). This access (approximately 3-4 cm) is free from problems, can be clearly seen, and is easy to learn. It ensures safe dissection in view and low-risk introduction of the implants.
Wound closure without tension using a 4.0 poliglecaprone 25 (Monocryl) intracutaneous suture ensures that the scar is as good as invisible if there is normal wound healing and good care is taken of the scar. Often this scar is less unsightly than the scar that is produced with axillary axis (1). With regard to the latter, patients often complain that they have an unsightly scar when naked. Periareolar access (2) is very rarely indicated. This may lead, in addition to visible scar formation, to sensitivity disturbances in the nipple area. Both forms of access (1 and 2) should be in the repertoire of a well-trained aesthetic breast surgeon. Since this manual is primarily intended to convey basic knowledge, the video and text will give detailed information about submammary, i.e., supramuscular, access. As an appendix to this chapter, reference is made to submuscular access, which is indicated if the skin is poor, in order to ensure better coverage of the implant and to avoid the phenomenon of rippling.
Submuscular access is more invasive since the pectoralis major has to be completely separated at its caudal and medial point of attachment. Detachment of the muscle makes the breast more susceptible to subsequent deformation. The nipple is not lifted upwards to such a large extent, and on the basis of our studies (comparison of 100 patients)
the fibrosis rate does not differ significantly between the submus-cular and supramuscular position (<4%). In most cases the implant may be placed above the muscle (in over two-thirds of our patient group).
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