Editor's note: With this issue, we introduce a new column we're calling First Person Surgical. In it, in the surgeon's own voice, we'll learn the heuristic techniques and lessons-learned that only hard-won years in the surgical suite can teach. If you'd like to tell your first-person story, not merely case studies, but making the case — both for your approach and its assumptions, those flawed and those proven out — please e-mail us at [email protected].
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| Dr. Pacik |
Any physician's practice evolves and changes over time. The breast augmentation that I do now is very different than the one I did 30 plus years ago, and more sophisticated than surgery done 10 years ago. I describe some of these changes as they relate to pain control, bottoming out, double bubble, improvement of inferomedial cleavage and capsular contracture.
PAIN CONTROL In 1996, I started leaving indwelling catheters in place for instillation of local anesthesia after augmentation mammaplasty. I had concerns that any contamination would lead to an infection of the implant pocket. Fortunately this has not been the case in almost 600 consecutive patients. The technique has been published in Plastic and Reconstructive Surgery 1,2 and describes a 90 percent efficacy rate comparable to narcotics. Our patients are grateful to have this additional method of pain control.
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| Figure 1 |
Over the years, I have found that intermittent bolus and continuous flow are both effective.3 Continuous flow maintains a steady state of pain control whereas intermittent bolus allows the patient to have control over when she needs analgesia. Some patients have minimal to no discomfort and may not need any instillations. Intermittent bolus is much less expensive ($10 versus $200 for continuous flow) and is the more favored application of indwelling catheters in my practice.
We start by injecting 20 cc of 0.25 percent bupivacaine with 1:400,000 adrenalin on each side using a spinal needle medially, centrally and laterally, as well as along the inframammary crease prior to surgery. Repeat doses are given by instillation through the indwelling catheters prior to discharge. Four to six hours later, the patient instills herself at home with 20 cc per side if needed and still has an extra dose, if needed, for the morning hours as well. Patients are seen the following morning and implant mobility exercises are taught. They are instilled with the local anesthesia about 30 minutes prior to teaching the exercises. A few years ago, we started aspirating the bupivacaine about one hour after the office instillation. We noted that some of our patients had a bloody aspirate (Figure 1). For these patients, we instill 20 cc of saline, have them jiggle their numb breasts, and re-aspirate. Often this results in blood-tinged fluid. The catheters are either removed, or left for a second day in about 18 percent of our patients.
ACCENTUATING INFEROMEDIAL CLEAVAGE Another variation that evolved with time dealt with the patient who has constriction of the inferior portion of the breast or presents with wide cleavage, often in association with lateral flare of the breasts. I felt that it should be possible to change the shape of the breast rather than just enhancing what the patient has naturally. I began working with the concept of asymmetrical lowering of the breast fold with more dissection of the inferomedial area than centrally or laterally. At first, this dissection was somewhat tentative, but with added experience, I began to understand the amount of lowering needed for a given problem.4
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| Figure 2 |
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| Figure 3 |
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Figure 4 |
The evolution of this technique has been quite helpful for creating additional rounding and cleavage in the inferomedial area of the breast often needed in the patient with constriction of the inferior pole (Figure 2) and the patient with lateral flare of the breasts (Figure 3). I also use this technique when a patient desires more cleavage and find it to be particularly helpful for the patient who presents with a constricted breast deformity (Figure 4).
Another benefit of this technique is when large implants are planned. Rather than a large dissection of the central part of the inframammary fold (IMF) to provide the needed space (which could result in bottoming out), more of the dissection is done in the inferomedial area, which has a wider zone of protective fascia. When dissecting the inferomedial area, it is important to do this under direct vision with good retraction, and to proceed slowly using cautery. One may encounter a perforator in this area, and blunt dissection alone could avulse this blood vessel and cause troublesome difficulty in controlling the bleeding. It is, therefore, important to stay high (anterior) during this portion of the dissection. When done slowly with good visualization and the use of cautery, the field is dry after the dissection.
DUAL-PLANE DISSECTION, MUSCULAR SLING, BLOCKING SUTURES As my practice evolved, I embraced the concept of dual-plane dissection as proposed by Tebbetts5. The pre-emptive control of hemostasis was found to be especially helpful. Over time, I began to notice an increasing incidence of bottoming out and felt that the disruption of the IMF was a contributing factor. I, therefore, went back to the drawing board to see if I could protect the IMF and still have a pleasing balance between the superior and inferior portions of the breast projection.
In the process, I used my live dissections to better understand the anatomy of the IMF. I noticed that the IMF was weakest laterally, more developed centrally, and most developed medially. I also noted that when using the
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| Figure 5 |
subpectoral approach, the area of entry under the pectoralis major could be dissected inferiorly with blunt dissection creating a sling of pectoralis major that would help support the implant (Figure 5). The rest of the medial dissection is then done both bluntly and under direct vision using cautery to carefully release the IMF, leaving some of the fascial fibers intact and being careful not to fall into the fatty tissues inferiorly. I, therefore, avoid dual-plane dissection, and instead dissect more in the medial zone when I need added space.
Once the entire dissection is complete, and I have lowered the IMF to my pre-op markings, I use two 3-0 polydioxane (PDS) sutures to secure the anterior rectus sheath to the superficial fascial system (SFS) as blocking sutures to further protect against bottoming out.
I feel that lateralization of the implant is similar to bottoming out, in that the lateral attachments of the breasts are violated. Though many articles in the literature discuss dissection to the mid-axillary fold, I feel that this is an error, and my own dissection does not go beyond the anterior axillary fold. This more limited dissection is helpful in three ways: patients do not like to have their inner arms rubbing against excessive lateral dissection, it helps prevent lateralization of the implant and gives more medial fullness.
MAMMARY PTOSIS, DOUBLE BUBBLE In an effort to help our patients with mammary ptosis, and especially for the patient who refuses a mastopexy, it is common to lower the IMF to help rotate the axis of the breast more superiorly. This maneuver is fraught with danger and often results in a double bubble. Double bubbles often require corrective surgery and make for both an unhappy patient and a stressed surgeon! Unfortunately, most of us have been there at some time. It is important to remember that ptosis is the patient's problem; a double bubble becomes the surgeon's problem. Further, without a breast lift, it is more difficult to integrate the ptotic breast with the implant, potentially creating yet an additional post-op deformity of the breast hanging off the implant. Therefore, if I cannot help a ptotic patient without doing a mastopexy, I would prefer not to do her surgery.
THE MAGIC OF BETADINE Since about 1985, I have been irrigating all surgical dissections and liposuction patients with a dilute solution of betadine (10 cc of betadine solution in 100 cc saline) both during the surgical procedure and prior to closure. All lap pads are soaked with this solution and wrung out. In this fashion, post-op infection is rare and capsular contracture almost unknown.
These are some of the concepts I have learned over time. I hope they will be helpful to others.
For more information: Dr. Pacik, a diplomate of the American Board of Plastic Surgery,has been in private practice in Manchester, N.H. since 1972. He limits his practice to aesthetic surgery, specializing in augmentation mammaplasty.
References
1 Pacik PT, Werner C, Jackson N, and Lobsitz C. Pain Control in Augmentation Mammaplasty: The Use of Indwelling Catheters in 200 Consecutive Patients. Plast Reconst. Surg. 2003;111:2090.
2 Pacik PT, and Werner C. Follow-up: Pain Control in Augmentation Mammaplasty: The Use of Indwelling Catheters in 350 Consecutive Patients. Plast Reconstr Surg. 2005;115:575.
3 Pacik PT. Pain Management in Augmentation Mammaplasty: A Randomized Comparative Study to Compare the Use of a Continuous Infusion Versus Self-Administration Intermittent Bolus of a Local Anesthetic. Aesth Surg J. 2004;24:523.
4 Pacik PT. Augmentation Mammaplasty: Enhancing Inferomedial Cleavage. Aesth Surg J. 2005;25:359.
5Tebbetts JB. Dual Plane Breast Augmentation: Optimizing Implant-Soft Tissue Relationships in a Wide Range of Breast Types. Plast Reconstr Surg. 2001;107:1255.
