PLASTIC SURGERY OF THE BREAST- Santa Barbara Plastic Surgery

SANTA BARBARA PLASTIC SURGERY DETAILS-  PLASTIC SURGERY OF THE BREAST

For those Santa Barbara plastic surgery patients who are interested a bit more on the technical side, the following is from a lecture series that I give operating room staff and residents on intra-operative procedure for various types of breast surgery, with some accompanying background information.  There are brief reviews of why certain breast plastic surgery procedures are performed and when those plastic surgery patients are the best candidates.  There is then a description of how I perform that plastic surgery procedure.  What is not covered completely is the extensive decision making process and the nuances that allow an optimal outcome- it’s hard to condense so many years of training and practice into a BLOG! 8) Explanation of many of these issues will be covered elsewhere on this website, and in extensive discussion with your plastic surgeon in Santa Barbara.

BREAST AUGMENTATION

WHY? Hypomastia, or underdevelopment of the breast tissue, can cause many secondary social and physical issues. Most commonly, women complain of a difficulty fitting into standard sized clothing and bathing suits. Alternatively, breast augmentation may alleviate self-consciousness and improve self-perception. This is a very personal decision that should be made by the patient herself.  Extraneous causes, such as major changes in life, or the effort to please a partner, should not effect the decision making process.

WHEN? Few plastic surgeons will perform breast augmentation before the age of 16 or 17 years old. Breast development may continue into the early 20s, and stability of breast size for at least a year should be a prerequisite for surgical intervention. In some cases where significant breast asymmetry hampers the ability to wear clothes, play sports, or causes social difficulties, this surgery may be done in the early teen years.

HOW?

1- Preoperatively the decision of incision- infra-mammary in the breast crease, or periareolar, has been made. The area of intended incision is infiltrated with 2% lidocaine with epinephrine, and after at least 7 minutes, the incision is made in the skin.
2- The incision is brought down to the level of the pectoralis with Bovie cautery.
3- The lower breast tissue is elevated off of the pectoralis muscle to the approximate level of the nipple.
4- Dissection in the avascular plane below the pectoralis muscle allows for a pocket to be made for the implant.
5- The inferior insertion of the pectoralis in elevated off of the chest wall from lateral to medial under direct vision, using a lighted retractor, providing the dual plane pocket for the breast implant.
6- Irrigation with antibiotic irrigation is undertaken and strict homeostasis is achieved with cautery.
7- The appropriate breast implant is chosen. A sizer may be used to approximate the postoperative appearance in order to help chose the correct sized implant.
8- If a saline breast implant is being used, it is bathed in antibiotic and evacuated of air, and 50cc of injectable sterile saline is infiltrated to aid in evacuating air, which now appears as a bubble in the implant. The breast implant is then inflated to the appropriate size.
9- If a silicone breast implant is used, it is bathed in antibiotic before being carefully placed through the incision to the pocket.
10- The same procedure is performed on the other breast.
11- All implant information must be kept for detailed records- for the hospital, for the patient, and for the surgeon.
12- The patient is sat up to evaluate the esthetic outcome, and any adjustments are made
13- Further antibiotic irrigation is used prior to closure in each breast implant pocket.
14- Closure of the wound is undertaken with deep 3.0 monocryl in the breast tissue as well as the dermis. 4.0 monocryl is used to close the skin, and mastasol and steri-strips are applied.
15- A lightly supportive garment or mesh gauze is placed with sterile 4×4 over the incisions.

VERTICAL BREAST LIFT (MASTOPEXY) OR REDUCTION

WHY? Excessive breast size causes neck, shoulder and back pain. Skin changes under the breast at the infra-mammary fold may also be problematic. Active women often complain of inability to perform sports and exercise.  Other women may complain of breasts that sag or droop and although they like the size of their breasts, they wish to have them returned to a youthful position.  A small amount of excision with this type of operation results in a lifting procedure, while a larger resection results in a breast reduction.  Minor aesthetic breast lifts may be performed with less invasive types of surgery.  Breast lifts may be used with breast implants to improve breast position as well as provide augmentation.

WHEN? Childhood endocrine abnormalities may lead to the need for breast reduction surgery as early as puberty, but this is rare. Breast size often increases during pregnancy, so there may be a preference to perform surgery following childbirth.  Often breasts return to their former size but may droop more than before pregnancy.  Aging or sometimes even simple breast form may manifest as drooping of breast tissue that is aesthetically displeasing to the patient.

HOW? The vertical scar technique is the most frequently used.

1- DILUTE epinephrine (1:200,000) is injected to the breast parenchyma, approximately 40cc in each breast, to help control bleeding during the dissection. 100 cc of this solution is placed in a sterile bowl, and placed on a side table or Mayo stand with a 20cc syringe and a spinal needle to use for infiltration. The surgeon will infiltrate the breasts with this prior to prepping and draping.
2- Tension is placed to the breast tissue to stretch the nipple complex. A lap sponge or rubber drain may be used with a Kocher clamp to provide this tension.
3- A 42mm cookie cutter template is used to mark the new complex.
4- The new nipple is incised.
5- The pedicle is de-epithelialized.
6- The central lower portion of the breast is resected appropriately leaving lateral and medial “pillars” to support the lower breast in the new position.  In a breast lift, skin is resected here rather than significant breast tissue.  Incisions in the breast tissue may be performed to allow folding of a flap of lower breast tissue into a position behind the upper breast to restore a youthful form.
7- The pedicle is trimmed of the excess breast tissue with a bovie or knife.
8- Any excised tissue is weighed to give some idea of the need for the amount of excision on the other side.
9- Hemostasis is achieved with cautery. Absorbable stitches may be required here for larger bleeding vessels.
10- Irrigation is performed.
11- The pedicles are re-approximated with stitches and the skin is closed with staples or stitches
12- The same procedure is performed on the other breast.
13- The patient is sat up to evaluate symmetry.
14- Adjustments are made with further excision if necessary. Further resected tissue must be put in the appropriate specimen bag to assure weight is correct on each side, and to assure that if cancer is found, the proper side is identified.  Liposuction may be used in the medial or lateral aspects of the breast to improve shape.
15- The 42mm cookie cutter is used to mark the area of the new nipple, and symmetry is evaluated. Some surgeons may have already cut a defect for the nipple and this step may not be required.
16- The new nipple area is incised and the nipple is delivered into the defect.
17- Final closure is obtained by removing the staples and sewing with interrupted 3.0 monocryl and running 4.0 monocryl. 5.0 monocryl may be used for the nipple.
18- Mastesol, steri-strips, Xeroform, and fluffs are applied under a surgical bra.

BREAST RECONSTRUCTION

PEDICLED TRAM

WHY? Using a patient’s own tissue from the abdomen allows for a more natural appearing result. Some women are not candidates for this pedicled operation, such as those who may have upper abdominal scars, smokers, diabetics, or others who may have diseases affecting the small blood vessels needed to supply the tissue of the flap. The blood must travel a far distance through the upper rectus abdominus muscle to reach the flap tissue, and so the blood vessels must be patent and in good shape. Obese women may have too much tissue for the small vessels to supply and these women may not be candidates. Only about 2/3 of the abdominal flap can survive on the upper blood supply, so patients needing more of the flap to construct a larger breast may need a free flap instead (see below).

WHEN? This operation, as is the case with other forms of reconstruction, may be performed at the same time as the mastectomy or following the mastectomy as a delayed procedure.

HOW? Pre-operative markings are made prior to surgery. Two bovies are required so one surgeon can work on the abdomen, dissecting out the flap, while the other can make the pocket for the flap to sit in on the chest wall. Often one bovie is set very low, at around 10 to protect the blood vessels while dissecting out the rectus muscle in the abdominal wound. This is the “cool” bovie. The other bovie remains set at 40.
1- The upper incision of the abdominal flap is made down to the fascia of the abdominal wall.
2- The skin and fat of the abdominal wall is dissected from the fascia of the abdominal wall muscles up to the level of the rib cage and xifoid. The scrub tech may be asked to retract the skin up while this dissection is performed with a hot bovie. Rakes or retractors may be needed here.
3- The patient is sat up to allow the edge of the upper abdominal wound to be pulled down to the marking at the lower end of the flap. This assures that closure of the abdominal wound will be possible following movement of the flap up to the chest.
4- Once this is confirmed, the patient may be returned to the supine position. The inferior marking is incised down to the level of the fascia of the abdominal wall.
5- The umbilicus is retracted toward the ceiling using two single hooks, and a fresh #15 blade is used to incise around the umbilicus. A super sharp or mets scissors may be used at this point to aid in the dissection.
6- The perforating blood vessels that communicate and supply the fat and skin of the flap from the underlying muscle, through the fascia in the region of the flap, are important here. The flap itself is lifted off of the underlying fascia except in the region of these blood vessels, which lie in two rows on the medial and lateral edges of the rectus muscle that is to be used for the pedicle (see #6 below). This is where the “cool” bovie may be used for careful dissection of the fat off of the portion of the abdominal fascia that is to be left behind, while not damaging the perforating blood vessels that must be found and left un-damaged.
7- The muscle pedicle is dissected at this point. For single side reconstructions, the opposite side rectus muscle is dissected. For bilateral reconstructions, both rectus muscles are dissected and the pedicle of the same side of the corresponding mastectomy defect is used for that reconstruction.
8- A marking pen is used to mark a strip of fascia from the flap up to the rib cage which corresponds to the rows of perforating blood vessels that supply the flap as described above. This marking is extended around the portion of the flap that has been left attached to the fascia, containing the perforating vessels, and meets in a V below the level of the flap.
9- A fresh #15 blade is use to incise these markings which exposes the medial and lateral portions of the rectus muscle.
10- The rectus muscle is then “shelled” out of the remaining portion of the tube of fascia that surrounds it. This may be done with a “cool” bovie or with a bipolar cautery.
11- The inferior portion of the rectus muscle is divided below the level of the flap. In this region, the lower blood supply to this muscle must be divided and ligated with a 3.0 vicryl tie. This is the vessel that would be dissected for use in a free flap (see below). In a pedicled flap, the blood supply is based on the superior vessel and so the inferior one is ligated and divided closer to the flap. The flap is now unattached, except for the pedicle attachment of the upper rectus muscle which has been dissected to the level of the rib cage.
12- The chest wall defect is made by the general surgeon performing the mastectomy, or if the case is a delayed reconstruction, the old scar must be excised and pocket fashioned above the pectoralis muscle, below the skin, to accommodate the TRAM flap.
13- A tunnel is made with the cautery, often using the long tip, between the chest and abdominal wounds.
14- The flap is passed through the tunnel and delivered to the chest wound. This is done very carefully to avoid tearing the flap from the muscle pedicle which is supplying the blood.
15- The flap is trimmed with the bovie or Mayo scissors, and may be partially de-epithelialized using the super sharp scissors to achieve symmetry.
16- The fascia that had surrounded the rectus muscle must be closed. An 0 looped nylon is used to run a stitch approximating the two free sides of the outer fascia, where the strip had been dissected in #8 above. If this is too tight to close easily, interrupted 2.0 or 3.0 vicryls may be used to reinforce the closure. If closure is still not possible, especially in bilateral cases where strips of fascia have been removed on each side, then a large piece of Marlex mesh may be required to allow closure of the abdominal fascia. This is sewn into place with interrupted 0 prolene.
17- 3-4 fully fluted Blake drains are used. One is placed in the axilla of each chest wall defect and two are placed into the abdominal wounds. These are sewn into place with 2.0 silk sutures.
18- Closure of all wounds is begun with 3.0 Monocryl. The patient is again flexed to facilitate closure of the abdominal skin. A fresh #15 blade is used to make a new defect in the abdominal wall where the umbilicus will be delivered. Mets scissors may be used to help spread the fat and fascia, and the umbilicus is delivered through this wound and sewn into place with interrupted 4.0 monocryl and running 5.0 monocryl.
19- Closure of all wounds is performed with interrupted 3.0 monocryl and running 4.0 monocryl.
20- Mastesol and steri-strips are applied, followed by Xeroform strips and fluffs. The dressings are secured with cover-roll tape.
21- A defect is cut in the tape to allow observation of the flap in the chest. A warm and pink flap indicates good blood flow following surgery. A laser Doppler is NOT usually used for pedicled TRAM flaps.
22- A hospital bed us used to transport the patient immediately following the procedure. THE PATEINT MUST REMAIN IN THE FLEXED POSITION or the abdominal closure will tear open. The bed is put into a flexed position before moving the patient, so the patient stays flexed during the transport (and for the following days in the hospital).

FREE TRAM

WHY? As above, the TRAM flap creates the most realistic breast reconstruction. When a pedicled flap cannot be performed because of concerns regarding blood supply, a free TRAM may be preferred. This is particularly the case in smokers, diabetics, obese patients, and those who need large reconstructions. Whereas in a pedicled flap, only about 2/3 of the abdominal flap may be utilized, a free TRAM allows the entire flap to be used. This flap is based on the shorter, larger caliber inferior blood vessels, and so a larger volume and pressure of blood is delivered to the flap allowing for better perfusion of the flap tissue in these cases. The disadvantages of this procedure is the longer operative time, the more involved technical portion of the operation, and the need for the microscope

WHEN? Same as pedicled TRAM above.

HOW? This operation requires special technical procedures and corresponding equipment. The microscope is used, as is micro vascular suture. Before the case, the microscope should be tested to make sure that all cords and connectors are available, and that all lenses are clean and properly installed. The patient is often reversed on the OR table to allow for the microscope to be put in position toward the head of the bed without the base of the operating table getting in the way, and to allow both surgeons to position themselves to perform the micro vascular portion of the case. The bed is also turned 180 degrees to allow access with the microscope to the chest area. This procedure shares many steps with the pedicled version, but has many important differences.
1- The chest wall pocket is made by the general surgeon or by the plastic surgeon as in the pedicled TRAM. The blood vessels which will be used in the chest to anastamose to the vessels of the free flap are dissected at the same time the other plastic surgeon is dissecting the flap from the abdomen. Again, two bovies are required.
2- A rib in the medial aspect of the chest wall is isolated near the sternum at its cartilaginous area. The pectoralis muscle is freed from this area using the bovie, and an incision in the perichondrium layer surrounding the rib cartilage is performed with a knife or bovie.
3- Periosteal elevators and rib dissectors are used to isolate the cartilaginous region of the rib, and this portion of the rib is removed. The “recipient vessels” (the internal mammary vessels) lie just below the deep layer of the tissue surrounding the rib. This connective tissue is incised and dissected with the bipolar cautery to isolate these vessels. The micro instruments may be used here to aid in dissection. Warm irrigation may be used at this point. Once the vessels in this area are dissected carefully, 20% Lidocaine is sprayed on the vessels. This is placed in a TB syringe connected to a 25 gauge anterior chamber catheter. This solution paralyzes the small nerve and muscle cells surrounding the blood vessels and allows them to dilate so they can be more easily sewn to the vessels of the flap.
4- Meanwhile, the upper incision of the abdominal flap is made down to the fascia of the abdominal wall.
5- The skin and fat of the abdominal wall is dissected from the fascia of the abdominal wall muscles up to the level of the rib cage and xifoid. The scrub tech may be asked to retract the skin up while this dissection is performed with a hot bovie. Rakes or retractors may be needed here. In this case, this maneuver releases the skin of the abdominal wall to aide in closure.
6- The patient is sat up to allow the edge of the upper abdominal wound to be pulled down to the marking at the lower end of the flap. This assures that closure of the abdominal wound will be possible following movement of the flap up to the chest.
7- Once this is confirmed, the patient may be returned to the supine position. The inferior marking is incised down to the level of the fascia of the abdominal wall.
8- The umbilicus is retracted toward the ceiling using two single hooks, and a fresh #15 blade is used to incise around the umbilicus. A super sharp or mets scissors may be used at this point to aid in the dissection.
9- The perforating blood vessels that communicate and supply the fat and skin of the flap from the underlying muscle, through the fascia in the region of the flap, are important here. The flap itself is lifted off of the underlying fascia except in the region of these blood vessels, which lie in two rows on the medial and lateral edges of the rectus muscle that is to be used for the pedicle (see #6 below). This is where the “cool” bovie may be used for careful dissection of the fat off of the portion of the abdominal fascia that is to be left behind, while not damaging the perforating blood vessels that must be found and left un-damaged.
10- The muscle pedicle is dissected at this point. For single side free reconstructions, the same side rectus muscle is dissected. For bilateral reconstructions, both rectus muscles are dissected and the pedicle of the same side of the corresponding mastectomy defect is used for that reconstruction.
11- A marking pen is used to mark a strip of fascia surrounding the area with the perforating blood vessels. This marking is extended around the portion of the flap that has been left attached to the fascia, containing the perforating vessels, and then extends inferiorly toward the lateral pubis. This allows exposure of the inferior vessels that must be dissected for a long length to allow attachment to the vessels in the chest. A Richardson retractor may be used to help with visualization here. Dissection may require ligation of side branches of the vessels using 4.0 vicryl or ligaclips.
12- The microscope should be draped and prepared at this point.
13- Once the lower abdominal vessels are isolated, the rectus muscle above the flap is divided since this portion of the muscle will not be needed as a pedicle- the blood flow will be through the vessels that are below when they are sewn to the vessels in the chest.
14- The microscope is positioned to allow visualization of the blood vessels in the chest wall, so everything is set up at this point. The surgeons may ask for stacks of folded towels to rest their wrists on while sewing under the microscope. This support allows for greater dexterity and less tremor under the magnification. Heparinized LR should be available for the upcoming portion of the case.
15- Often the surgeons will take a short break at this point, just before the flap is isolated and the micro vascular portion of the case begins. Any change in staff should be performed now, as staff changes during the micro vascular portion of the case can lead to miscommunication and delay during a time dependant and very technical portion of the operation.
16- Following the break, the lower abdominal vessels are divided with sharp scissors and the ends of the vessels left behind are ligated with 3.0 vicryl ties. The ischemic time for the flap has now begun, and it must be attached to the vessels in the chest as soon as possible to prevent death of the tissue of the flap.
17- The flap is flushed with heparinized LR to flush out the remaining blood within the tissue of the flap. This solution is placed in a 10cc syringe connected to a 25 gauge anterior chamber catheter. If flushing is not performed, the blood in the tissues of the flap will clot in the time it takes to re-connect the blood flow, and this will prevent perfusion of the flap once the vessels are attached to the chest wall vessels. This flushing is performed through the artery of the flap until the liquid seen from the vein of the flap is clear, signifying that the blood has been flushed from the flap tissue. The cardiac suction tip should be available on the suction tubing for this part of the case.
18- Small bulldog micro vascular clamps are used to clamp the proximal ends of the vessels in the chest wall and the distal ends are divided and ligated with small or medium ligature clips. Heparinized LR is used to flush the blood from the open ends of the chest wall blood vessels, again to prevent clotting and to aid in visualization of the blood vessel wall.
19- The blood vessels are sewn together using fine suture. Depending on the size and appearance of the vessels, any suture from 8.0 to 10.0 nylon may be used. The primary surgeon will use the micro needle holders, as well as the angled forceps to allow instrument ties to be made on the fine sutures. The assistant will use two platformed micro instruments to allow traction on sutures placed to stabilize the vessels. Micro scissors will be used to cut the suture and should be available to the assistant when needed. Micro sponges or wicks may also be needed.
20- Following connection of the blood vessels, the small bulldog clamps are removed to allow flow through the flap. If the vessels are thought to be narrow and in spasm, further 20% Lidocaine may be required to bathe that area to facilitate dilation. Further dissection or even revision of the anstamoses may be needed. Bleeding areas may be observed, or further stitching may be required under the microscope. Once flow is re-established, the ischemic time is over. The microscope may be rotated out of position but should remain sterile and prepared in case problems arise and it is needed again.
21- The flap is trimmed with Mayo scissors or bovie, and may be partially de-epithelialized using the super sharp scissors to achieve symmetry. A 3.0 monocryl may be used to re-attach the pectoralis muscle in the area of the previous rib resection.
22- The fascia that had surrounded the rectus muscle must be closed. An 0 looped nylon is used to run a stitch approximating the two free sides of the outer fascia, where the strip had been dissected in #8 above. If this is too tight to close easily, interrupted 2.0 or 3.0 vicryls may be used to reinforce the closure. If closure is still not possible, especially in bilateral cases where strips of fascia have been removed on each side, then a large piece of Marlex mesh may be required to allow closure of the abdominal fascia. This is sewn into place with interrupted 0 prolene.
23- 3-4 fully fluted Blake drains are used. One is placed in the axilla of each chest wall defect and two are placed into the abdominal wounds. These are sewn into place with 2.0 silk sutures.
24- Closure of all wounds is begun with 3.0 Monocryl. A fresh #15 blade is used to make a new defect in the abdominal wall where the umbilicus will be delivered. Mets scissors may be used to help spread the fat and fascia, and the umbilicus is delivered through this wound and sewn into place with interrupted 4.0 monocryl and running 5.0 monocryl.
25- Closure of all wounds is performed with interrupted 3.0 monocryl and running 4.0 monocryl.
26- Mastesol and steri-strips are applied, followed by Xeroform strips and fluffs. The dressings are secured with cover-roll tape.
27- A defect is cut in the tape to allow observation of the flap in the chest. A warm and pink flap indicates good blood flow following surgery.
28- The laser Doppler is most often used to monitor the flap postoperatively. This is done for free flaps only, and requires both the monitor and the probe. The probe is secured to the skin with 2.0 silk sutures on cutting needles, along with further Mastesol and steri-strips.
29- A hospital bed us used to transport the patient immediately following the procedure. THE PATIENT MUST REMAIN IN THE FLEXED POSITION or the abdominal closure will tear open. The bed is put into a flexed position before moving the patient, so the patient stays flexed during the transport (and for the following days in the hospital).

TISSUE EXPANDER

WHY? Some patients are not candidates for any tissue flap, because of prior medical or surgical history. Other patients may prefer the less invasive alternative of a prosthesis rather than the involved surgery of a TRAM flap. Some patients may be too thin to allow an adequate reconstruction with a minimal amount of abdominal tissue. The expander/implant option is less aesthetically pleasing, but requires less dissection, less anesthesia time, and does not have the risks of the second abdominal wound.

WHEN? As with other reconstructive options, this may be performed in an immediate or delayed fashion. The expander is placed first to allow expansion of the overlying tissue to accommodate the permanent implant which is placed at a later operation. The expansion is performed via several visits to the office following the surgery. At these visits, the chest wall is sterilized with betadyne and a needle connected to a syringe and a bag of injectable saline is used to inflate the expander by 50-100cc at a time. The needle is inserted through the chest wall into the firm reservoir area of the expander, which is found using a magnetic locator device. Several weeks are allowed to pass between inflations to allow the overlying tissue to stretch and relax.

HOW? Pre-operatively, the patient’s chest wall and breast tissue are measured and an appropriate sized tissue expander is ordered. One or two extra expanders are usually ordered in case there is a problem with one of them.

1- If the reconstruction is immediate, then the general surgeon has made the chest wound. If not, the plastic surgeon excises part of the scar with a knife and dissects down to the level of the pectoralis muscle.
2- The lateral edge of the pectoralis is found, and the bovie is used to dissect the muscle medially from the underlying rib cage.
3- Laterally, the serratus muscle is dissected and lifted in the same manner.
4- Significant bleeding can be incurred during the dissections, particularly medially. If possible, the bovie is used to control this bleeding, but 3.0 monocryl on a tapered needle may be required to ligate vessels.
5- Following dissection of an adequate pocket, the wound is washed with irrigation fluid mixed with Ancef, and careful inspection for bleeding is performed.
6- A towel is soaked in the Ancef irrigation and placed on the chest wall below the wound to prevent the implant from being contaminated by any skin bacteria.
7- The expander is identified and noted to be the correct one before it is opened. The inner packaging is opened by the scrub tech or the surgeon only, and Ancef irrigation is placed in the dome shaped packaging to bathe the expander. Infection of the expander is disastrous, and so we often go to ridiculous lengths to prevent any chance of contamination. The surgeon may ask to change gloves.
8- Next, air must be evacuated from the expander. As little as 1cc of air in the expander can cause a sloshing sound with movement and this is not appreciated by the patient. Air evacuation is performed by injecting 50cc of injectable saline via a 20 gauge needle into the port portion of the expander. The needle is placed to a short piece of IV tubing, which is connected to a 3 way stopcock and a 60cc syringe. The stopcock allows the expander to be closed off to the outside air as the syringe is removed and replaced to the needle apparatus. The IV tubing prevents excessive motion of the needle while the syringe and expander are being manipulated. Alternatively, some surgeons may use the pre-packaged fill kits supplied with the expander.
9- Following the injection of the 50 cc of saline, the expander is manipulated so that the air rises to the top of the expander where the needle is placed, and an empty syringe is used to suck out the air. The stopcock is used to open and close the implant to the syringe, allowing evacuation of as much air as possible.
10- Further saline may be injected to the expander following removal of the air, depending on the size of the chest wound. Throughout this manipulation of the implant, it is left in the half-dome packaging and bathing in Ancef irrigation.
11- The needle is then removed, and the expander is inserted into the chest wound. An army/navy retractor may be used to open the wound at this point.
12- The expander is properly positioned, and the closure begins.
13- Re-approximation of the muscle layers is performed with a 3.0 monocryl. This is done very carefully to prevent damage to the underlying expander. Muscle coverage is important in this case, more so than in breast augmentation, because subsequent stretching of the tissue necessitates as many layers of coverage of the expander as possible. The muscle coverage also helps to mask the “balloon-like” feel of the expander or implant since there is no overlying breast tissue.
14- Skin closure is performed with 3.0 and 4.0 monocryl, followed by Mastesol and steri-strips. No bra or constrictive dressing is required.

IMPLANT

WHY? See “EXPANDER” above. Implants are placed following expansion of the chest wall, and do not have the same type of port area which can be felt as a firm spot.

WHEN? Following completed expansion of the tissue of the chest wall, the skin and muscle are allowed to relax into their new stretched position over a couple of months. At this point, the patient is ready for the second stage of the operation which entails removal of the expander and placement of the permanent implant.

HOW? Implant placement is much like expander placement. There is no firm port area. Instead, the port is simply a valve on the back wall of the implant, and so it is much easier to fill and evacuate air with this set-up.
1- The scar of the previous expander placement is incised and a bovie is used to dissect down to the level of the expander.
2- The expander is isolated from the surrounding tissue bluntly, often with a finger. Subsequently the expander is removed from the wound. Ancef irrigation is placed into the wound and the implant is prepared.
3- The style and size of the implant is checked before opening. The inner packaging is opened only by the scrub tech or surgeon. The implant is bathed in Ancef irrigation.
4- Air is evacuated from the implant in the same manner as above with the expander, except no needle is needed as the valve connects to the inflation tubing supplied with the expander. A 60cc syringe is still required, as is a 3-way stopcock, to evacuate the air.
5- A towel soaked with Ancef irrigation is placed on the chest wall below the wound, and the implant is placed into the wound.
6- After positioning, the implant is inflated with injectable saline. Careful accounting of the amount of fluid infused is performed by everyone involved in the case.
7- Following complete inflation, the tubing is removed from the valve of the implant, and the wound is closed with 3.0 and 4.0 monocryl, Mastesol, and steri-strips. Some surgeons may use an ace wrap or soft bra to aid in positioning of the implant.