Modified Cautery Tip and Dissection Technique for Subpectoral Breast Augmentation

Abstract

In performing subpectoral breast augmentation, monopolar electocautery (more properly called the electrosurgical unit, or ESU) is frequently applied to achieve adequate hemostasis during the course of dissection. One problem, however, is that the electrical current can cause muscle contraction; when this occurs, the muscle may impale itself on the cautery tip, causing deep muscle belly bleeding. This deep bleeding, which is often at the cranial end of the subpectoral pocket, can be difficult to locate in the substance of the muscle and more difficult to stop, especially through the small incision used for breast augmentation. This is a common complaint I hear among colleagues, and these episodes are not infrequent. They can add 10 to 15 minutes of operating room time, with added expense, prolonged anesthesia time for the patient, greater chance of postoperative bleeding, and certainly increased frustration and exhaustion for the surgeon. A number of factors come into “play” in this situation. The first is the frequency of the ESU electrical current that is passing through the patient: the higher the frequency, the less muscle contraction that will occur (although some will still occur in certain circumstances). Most ESU devices have a fixed frequency range. Another factor is the ESU setting—that is, whether “cut” or “coagulation” is chosen. These settings are somewhat arbitrary and are not true indicators of their function. The cut mode is typically a better choice for dissection and for deep bleeding coagulation because there is more energy penetration at this setting. A third factor is the dissection tip itself. I use a blade or spatula …