Enlarging mammoplasty: spherical endoprosthesis implantation

Since the U.S. Food and Drug Administration approved anatomical implants in 2012, [ 1 ] this new technology has become increasingly popular in the United States for breast reconstruction. [ 2 ], [ 3 ] The reported benefits of the spherical shape of the implants include superior projection of the lower and upper pole, giving a more “natural” appearance to the breast. [ 4 ], [ 5 ]

The decision to use a spherical or specially shaped silicone gel implant is usually based on the patient and breast characteristics.

Preoperative marking and approaches

Before the operation, with the patient in a sitting position, the midline and submammary fold are marked, as well as the boundaries of the tissue detachment zone, the diameter of which should slightly exceed the diameter of the prosthesis. On the side of the upper pole of the mammary gland, the tissue detachment zone should be 2-3 cm larger.

Most often, implantation of endoprostheses is performed through submammary, axillary (transaxillary), trans- and periareolar approaches. Existing postoperative scars can also be used for insertion of endoprostheses. Each of the named approaches has its own advantages and disadvantages. [ 6 ]

The main advantages of the submammary access are the possibility of an ideally precise and symmetrical (on both sides) formation of a pocket for the endoprosthesis, as well as the possibility of performing a thorough stop of bleeding. The length of such an incision, as a rule, does not exceed 5 cm, and its line corresponds to the submammary fold. The access is marked as follows: a perpendicular is lowered from the nipple to the submammary fold, then points are marked from the intersection of the lines 1 cm inward and 4-4.5 cm outward. It is important that the distance from the center of the areola to the submammary fold is the same on both sides. On average, it varies from 6 to 8 cm and depends on the configuration of the chest and the planned volume of the prosthesis.

The advantage of the axillary approach is that the postoperative scar is in a hidden area. However, it is more difficult for the surgeon to form a cavity of the appropriate size, achieve symmetrical placement of the prostheses and carefully stop bleeding. [ 7 ]

The periareolar incision is located on the border of pigmented and light skin, which makes it less noticeable. Its disadvantages include fairly frequent damage to the terminal fibers of the sensitive branch of the IV intercostal nerve, direct damage to the gland tissue, and limitations in the use of certain types of prostheses (prostheses filled with non-flowing gel).

Transareolar access has even more disadvantages. In addition to damage to glandular tissue, there is microbial contamination of the pocket being formed by microflora from glandular tissue, which, according to modern concepts, is one of the reasons for the formation of a powerful fibrous capsule around the prosthesis. [ 8 ]

Technique of operation

The operation is performed under general anesthesia with the patient lying on the operating table on her back with her arms abducted at an angle of 90°. The tissue detachment area is additionally infiltrated with a 0.5% lidocaine solution with the addition of adrenaline at a dilution of 1:200,000. When using the inframammary approach, the skin and subcutaneous fat are dissected to the fascia of the pectoralis major muscle, after which they begin to form a cavity for the implant. Depending on the placement of the endoprosthesis, a pocket for it is formed above or below the pectoralis major muscle. In accordance with the marking boundaries, tissue detachment above the muscle is performed between the layers of the deep fascia, without damaging the fascial sheath of the gland. When forming a cavity along the outer part of the gland, it is necessary to be extremely careful not to damage the anterolateral sensitive branch of the IV intercostal nerve, which innervates the nipple-areolar complex. Certain advantages at this stage of the operation are provided by the use of an electric knife with attachments of different lengths. Ultimately, the size of the pocket should be slightly larger than the size of the prosthesis. [ 9 ]

When placing the prosthesis under the pectoralis major muscle, to prevent displacement of the implant under the action of its contractions, the formation of the cavity is completed by cutting off the pectoralis major muscle from the place of its attachment to the sternum and ribs.

The use of a head-mounted fiber optic light, good instrumentation, and electrosurgical equipment is essential to ensure thorough bleeding control.

After a control examination, the formed cavity is washed with an antibiotic and antiseptic solution.

An important stage of the operation is the installation of the endoprosthesis into the formed bed. Mammoprostheses with a textured surface are inserted into the pocket using a special polyethylene "sleeve" so as not to injure the edges of the wound and not to damage the surface of the implant. When the prosthesis is correctly placed, its center is usually located in the projection of the nipple, which is checked with the patient in a semi-sitting position on the operating table. [ 10 ]

A mandatory element of the final stage of the operation is drainage of the wound with tubes (with active aspiration of the wound contents). Subsequent suturing of the fascia requires the use of a Buyalsky spatula to protect the prosthesis from damage by the needle. After suturing the subcutaneous fat, an intradermal suture is applied to the skin - continuous or nodular. The operation is completed by applying an elastic compression bandage.