Subpectoral Breast Augmentation Research Articles

Pharmacokinetics of Repeated Melatonin Drug Administrations Prior to and After Surgery.

Recent clinical studies have documented the analgesic, anti-inflammatory, antioxidative and anxiolytic effects of exogenous melatonin. The pharmacokinetic properties of melatonin have primarily been investigated in experimental studies. The aim of this study was to estimate the pharmacokinetics of melatonin in patients undergoing surgery and general anesthesia. The study was designed as a prospective, two-phase cohort study. Patients were candidates for subpectoral breast augmentation surgery, and surgical procedures were performed by a single surgeon. The perioperative treatment protocol was standardized between patients. During the study, each patient received two separate oral administrations of melatonin 10mg. Melatonin was administered 60min before surgery, and at 9:00 p.m. the evening after surgery. The pharmacokinetic variables absorption half-life (t ½ absorption), time to maximal plasma concentration (T max), maximal plasma concentration (C max), elimination half-life (t ½ elimination), and area under the melatonin plasma concentration-time curve from time zero to infinity (AUC ∞) were estimated for both study phases. Median (interquartile range) values of t ½ absorption and T max were significantly increased during the postoperative phase [10.8 (6.9-15.1)min; 90.0 (48.8-120.0)min] compared with perioperatively [9.5 (6.3-16.5)min; 30.0 (15.0-30.0)min] (p=0.034; p=0.002), respectively. C max values were significantly higher during surgery [5497.5 (2077.1-13,233.8) pg/ml] compared with postoperative values [2340.5 (1672.4-8871.4) pg/ml] (p=0.005). Correspondingly, t ½ elimination was significantly extended during the postoperative phase [103.5 (57.8-237.8)min] compared with the perioperative phase [60.5 (47.8-83.6)min] (p=0.015). AUC ∞ did not differ between the study phases (p>0.05). These preliminary results indicate that postoperative melatonin dose should be augmented compared with preoperative administration if corresponding melatonin plasma levels are intended. Furthermore, postoperative administration times should be advanced compared with preoperative administration.

Comparison of Reconstructive Outcomes in Breast Cancer Patients With Preexisting Subpectoral Implants: Implant-Sparing Mastectomy With Delayed Implant Exchange Versus Immediate Tissue Expander Reconstruction.

Women who have undergone prior augmentation mammoplasty represent a unique subset of breast cancer patients with several options available for breast reconstruction. We performed a single institution review of surgical outcomes of breast reconstruction performed in patients with breast cancer with prior history of subpectoral breast augmentation. Institutional review board-approved retrospective review was conducted among patients with previously mentioned criteria treated at our institution between 2000 and 2014. Reconstructions were grouped into 2 categories as follows: (1) removal of preexisting subpectoral implant during mastectomy with immediate tissue expander placement and (2) implant-sparing mastectomy followed by delayed exchange to a larger implant. We reviewed demographics, tumor features, and reconstruction outcomes of these groups. Fifty-three patients had preexisting subpectoral implants. Of the 63 breast reconstructions performed, 18 (28.6%) had immediate tissue expander placed and 45 (71.4%) had implant-sparing mastectomy followed by delayed implant exchange. The groups were comparable based on age, body mass index, cancer type, tumor grade, TNM stage at presentation, and hormonal receptor status. No significant difference was noted between tumor margins or subsequent recurrence, mastectomy specimen weight, removed implant volume, volume of implant placed during reconstruction, or time from mastectomy to final implant placement. Rates of complications were significantly higher in the tissue expander group compared to the implant-sparing mastectomy group 7 (38.9%) versus 4 (8.9%) (P = 0.005). Implant-sparing mastectomy with delayed implant exchange in patients with preexisting subpectoral implants is safe and has fewer complications compared to tissue expander placement. There was no difference noted in the final volume of implant placed, time interval for final implant placement, or tumor margins.

A Muscular Etiology for Medial Implant Malposition Following Subpectoral Augmentation.

Implant malposition is becoming an increasingly recognized complication following subpectoral breast augmentation. Although several causes of medial malposition have been previously demonstrated, medial implant malposition secondary to unintended pectoralis muscle slips has not been previously described. The goal of this study is to describe a form of medial implant malposition caused by pectoralis major and minor musculature vectors on the implant. The primary investigator performed a retrospective review of all patients who underwent revisional breast surgery for the diagnosis of symmastia or medial implant malposition following subpectoral augmentation. Those patients with muscular-type etiology for medial implant malposition were identified. Five patients with pectoralis muscle slips causing medial implant malposition were identified. The pectoralis muscle slips were successfully diagnosed on preoperative exam and corrected with specific surgical procedures aimed at balancing surrounding forces and thus correcting malposition. Pectoralis muscle slips contributing to medial malposition can be found in some patients after subpectoral breast augmentation. The etiology of this deformity is unknown, but theorized to be caused by anatomic predisposition, with slips inadvertently formed during subpectoral pocket formation arising from the pectoralis minor and/or incompletely released or accessory pectoralis major muscles.

The Delay Fill Technique: A Safer Approach to Combination Augmentation Mastopexy.

Combining breast augmentation with mastopexy is a challenging procedure that has a relatively high revision rate in the literature. Some surgeons prefer a two-stage procedure to avoid the potential for skin flap or nipple-areolar complex necrosis that can occur with a one-stage procedure. The authors compared 101 patients who had subpectoral breast augmentation with immediate implant fill and mastopexy with 203 patients who had subpectoral breast augmentation with delayed (10-14 days) implant fill and mastopexy. They found the revision rate for immediate implant fill was 24%; in the delayed implant fill group, the revision rate was 10.3%. Patients had soft tissue-related complications in 16% of the immediate fill group and in 2% of the delayed fill group. Delaying implant fill in combined breast augmentation mastopexy significantly reduces the risk of soft tissue-related complications and revision procedures; the delay flap phenomenon is responsible for fewer wound-healing complications when implant fill is delayed during a combined augmentation mastopexy procedure.

Anatomy of the sternal origin of the pectoralis major: implications for subpectoral augmentation.

The pectoralis major typically is manipulated for implant coverage and pocket design in subpectoral breast augmentation. An understanding of its anatomy can guide successful creation of the implant pocket. The authors evaluated the anatomy of the sternal origin of the pectoralis major to inform surgical planning, help establish a technique for subpectoral augmentation mammaplasty, and identify the most common locations of perforators. The sternal origins of 24 pectoralis major muscles were dissected and examined in 15 female cadavers to determine the structure and width of the pectoralis major sternal origin and its relationship to the locations of internal mammary perforators. The average width of the sternal origin of the pectoralis major was 7.1 mm (range, 3 mm-1.8 cm). This width decreased slightly from the second rib to the second intercostal space and then increased progressively in the caudal direction toward the fifth rib. The sternal origin terminated an average of 5.4 mm (range, 1-16 mm) from the midline, with the greatest distance at the fifth rib and large variability throughout. A row of perforators from the internal mammary artery traversed the subpectoral space an average of 2.7 cm from the midline (range, 1-3.7 cm). The sternal origin of the pectoralis major was thin and highly variable, suggesting that its partial release for implant medialization during subpectoral augmentation is unsafe.

Modified Cautery Tip and Dissection Technique for Subpectoral Breast Augmentation

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 …

Selective ultrasound guided pectoral nerve targeting in breast augmentation: How to spare the brachial plexus cords?

Subpectoral breast augmentation surgery under regional anesthesia requires the selective neural blockade of the medial and lateral pectoral nerves to diminish postoperative pain syndromes. The purpose of this cadaver study is to demonstrate a reliable ultrasound guided approach to selectively target the pectoral nerves and their branches while sparing the brachial plexus cords. After evaluating the position and appearance of the pectoral nerves in 25 cadavers (50 sides), a portable ultrasound machine was used to guide the injection of 10 ml of 0.2% aqueous methylene blue solution in the pectoral region on both sides of three Thiel's embalmed cadavers using a single entry point-triple injection technique. This technique uses a medial to lateral approach with the entry point just medial to the pectoral minor muscle and three subsequent infiltrations: (1) deep lateral part of the pectoralis minor muscle, (2) between the pectoralis minor and major muscles, and (3) between the pectoralis major muscle and its posterior fascia under ultrasound visualization. Dissection demonstrates that the medial and lateral pectoral nerves were well stained while leaving the brachial plexus cords unstained. We show that 10 ml of an injected solution is sufficient to stain all the medial and lateral pectoral nerve branches without a proximal extension to the cords of the brachial plexus.

Three-Dimensional Evaluation of Breast Augmentation and the Influence of Anatomic and Round Implants on Operative Breast Shape Changes

Currently, postoperative outcome analysis in breast augmentation is essentially subjective, and objective evaluation of treatment efficacy is lacking. This study evaluates the influence of anatomic and round implant parameters on breast contour changes after subpectoral breast augmentation using three-dimensional (3D) surface imaging. 3D surface breast scans of 17 patients (34 breasts) undergoing subpectoral breast augmentation with round implants and of ten patients (20 breasts) receiving anatomic implants via an axillary approach under endoscopic assistance or a submammary fold incision were obtained before and 6 months postoperatively. 3D linear distance, breast volume, and surface measurement were correlated with the implanted round and anatomic implant parameters, and the resulting breast shape changes were evaluated. Total breast volume changed in correlation with the implant size (2.4% difference; r=0.894; p<0.001). Implant volume and type influence the nipple-to-inframammary fold distance (N-IMF). Every inserted 100 ml implant volume enlarges the N-IMF distance by 0.8 cm (anatomic>round; p=0.01). Postoperatively, the IMF dropped by an average of 1.3 cm for round implants and by 1.1 cm for anatomic implants, without relevant differences between the applied surgical incision and the selected implants (p>0.05). Breast projection increased significantly more with anatomic implants (2.4 cm) than with round implants (1.7 cm) (p=0.01). The breast projection increase was 22% less than expected for round implants and 25% less than expected for anatomic implants based on the manufacturer implant parameters (p<0.01), without essential differences regarding the surgical incision. 3D breast shape changes induced by round and anatomic implants after subpectoral augmentation mammaplasty are objectively documented including breast projection, volume, and N-IMF distance changes. 3D surface imaging may have a potential clinical contribution to objective surgical outcome research. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Accelerated Partial Breast Intensity-Modulated Radiotherapy in Women Who Have Prior Breast Augmentation

Purpose To examine the outcome of breast cancer patients who have prior breast augmentation treated with lumpectomy followed by accelerated partial breast external intensity-modulated radiotherapy (APBIMRT) with image-guided radiotherapy (IGRT). Methods and Materials Four patients with previous elective subpectoral breast augmentation were enrolled on this APBIMRT trial. These four patients were treated with 10 equal twice daily 3.85 Gy fractions over 5 consecutive days (total dose of 38.5 Gy) using APBIMRT and IGRT. Patients were assessed for pain and cosmetic outcome (physician and a patient self-assessment). Results At last follow-up, two patients reported an excellent cosmetic results (at 2 years and at 8 months, respectively), one reported good cosmetic results (at 2 years), and one reported poor cosmetic results (at 20 months). Physicians rated the cosmetic outcomes as excellent in two (CEL; at 2 years and 8 months, respectively), good in one (CEL; at 20 months) and excellent in one (KTH; at 2 years). Three patients reported no breast/chest wall pain (two at 2 years and one at 1 year) and the fourth reported mild pain (at 20 months). The mean percent volume of ipsilateral breast receiving 100%, 75%, 50%, and 25% of the prescribed dose was 7.28%, 17.55%, 24.33%, and 33.1%, respectively. The mean breast, planning target volume (PTV), and implant volumes were 399.88 cc, 43.55 cc, and 313.36 cc, respectively. The mean breast prosthesis/total volume (breast tissue plus prosthesis) ratio was 44.55%. The mean PTV/ipsilateral breast and PTV/total volume ratios were 11.1% and 6.1%, respectively. Conclusion The results show that a regimen of APBIMRT with IGRT is possible in patients who have prior breast augmentation.

Three-dimensional evaluation of breast contour and volume changes following subpectoral augmentation mammaplasty over 6 months

Changes in breast-morphology occur after all types of breast surgery, but a systematic and objective surgical result assessment is currently lacking. Three-dimensional (3-D) surface imaging offers the ability to quantitatively evaluate breast contour, shape, surface and volume changes after surgery. This study evaluates 3-D breast contour and volume changes after breast augmentation over time. 3-D surface imaging of 14 subpectoral breast-augmentation patients (n = 28 breasts) were accomplished over six time periods (preoperative (OP), post-OP 1: 2-3 days; post-OP 2: 1 week; post-OP 3: 1 month; post-OP 4: 3 months; and post-OP 5: 6 months after surgery) and linear-distance measurement, breast volume and surface changes were analysed. 3-D breast-contour- and volume variations are expressed in percentage changes over time. All breast measurements changed significantly between pre-OP and post-OP 1 (Friedmann test, p = 0.001-0.025). First significant postoperative changes over time compared with post-OP 1 for breast volume, surface, sternal notch to nipple and nipple to inframammary-fold-distance measurements are quantifiable after 1 month (post hoc Wilcoxon test, p = 0.001 for all) with further relevant breast volume (post hoc Wilcoxon test, p = 0.041) and surface changes (post hoc Wilcoxon test, p = 0.037) between months 1 and 3 after surgery. The inframammary fold dropped by 1.4 cm after 6 months and final breast volume ± 0.5% is reached between months 1 and 3 after surgery. Valuable reductions in breast contour and volume by nearly 85% are also reached after 1 month (Wilcoxon test, p = 0.001) and changed to 98% after 3 months and 100% after 6 months. Breast morphological changes following subpectoral breast augmentation are completed after 3 months. 3-D surface imaging may play a part in comparing different breast-augmentation techniques.

Survey of satisfaction in patient with modified subpectoral and subglandular breast augmentation

Objective To investigate the different pectoral and subglandular breast augmentation. Methods procedure effects in patients with modified sub Patients with modified subpectoral breast aug mentation （10 cases） and subglandular breast augmentation （10 cases） were randomly selected, and saris factory surveys to the procedures were conducted in the two groups of patients, including breast touchfeeling, dynamic change, as well as selLfeeling and spouse-feeling. Results By the comparison of sub glandular with subpectoral breast augmentation, touch-feeling was excellent in the former group, with breast spreading out to bilateral side in horizontal position. The breasts had different changes with different posture and natural movement. Spouse was more satisfactory to the former than the latter group. Conclusion Subglandular breast augmentation has natural shape, dynamic changes and fidelity of the re al, especially in horizontal position, which is more conformable to the standards of patients and their spouse, and better than subpectoral breast augmentation. Key words: Implant; Mammary augmentation; Body posture; Dynamic feeling

Unexplained Massive Galactorrhea following Bilateral Subpectoral Breast Augmentation: Report of a Case

Galactorrhea, although a fairly common condition in a gravid or recently postpartum female, is rarely seen as a complication of breast augmentation or reduction. Although sporadic cases have been documented in the literature after cosmetic and reconstructive breast surgery, documented evidence of the cause of the abnormal lactation, save the identification of a pituitary prolactinoma, remains speculative at best. This case report involves a 32 y.o. Hispanic female who underwent elective bilateral subpectoral saline breast augmentation and developed massive galactorrhea in the immediate postoperative period.

Effect of Sustained-Release Lidocaine on Reduction of Pain After Subpectoral Breast Augmentation

Subpectoral breast augmentation is a popular procedure that increases the attractiveness of the female breast. However, this surgical procedure often causes postoperative breast pain. The author reports a new method of controlling postoperative breast pain following subpectoral augmentation. Thirty patients were randomly divided into 3 groups of 10 patients each. In all patients, silicone gel prostheses were placed in the subpectoral pocket. Patients in group A received 7.5 mL of 3.5% lidocaine dissolved in fibrin glue. Group B received 7.5 mL of lidocaine alone, and those in group C received 7.5 mL of fibrin glue alone. Breast pain was observed for 1 week postoperatively for all 3 groups. Patients completed questionnaires on each postoperative day in which pain assessment was scored according to a 0 to 3 scale: 0 equaled "no pain" and 3 equaled "worst pain." Postoperative breast pain reported by patients in group A was significantly less than that reported by patients in groups B and C (P < .05). Sustained-release lidocaine applied in the subpectoral pocket significantly reduced postoperative pain and discomfort without complications for patients who received cosmetic subpectoral breast augmentation. The relatively small size of the patient group limits the impact of these results; a much larger randomized, double-blind study is planned.

Efficacy of Pocket Irrigation With Bupivacaine and Ketorolac in Breast Augmentation

Breast augmentation is the most common cosmetic surgery procedure performed in the United States. The optimal approach to postoperative pain management in these patients, however, has yet to be determined. The objective of this study was to investigate the efficacy of pocket irrigation with bupivacaine and ketorolac in reducing pain, narcotic use, and methocarbamol use following subpectoral breast augmentation. A prospective, double-blinded, randomized trial was performed. Fifty primary breast augmentation patients were randomized to 1 of 2 treatment groups: 1) pocket irrigation with bupivacaine and ketorolac, and 2) no pocket irrigation. Patients who received pocket irrigation had significantly lower Visual Analog Pain Scores in the early postoperative period (1 and 6 hours postoperatively). There was no difference in early postoperative narcotic use in patients who received pocket irrigation and those who did not. Patients who received pocket irrigation, however, reported higher narcotic use at 1-3 days following surgery. There was no difference in postoperative methocarbamol use between patient groups. This study suggests that pocket irrigation with bupivacaine and ketorolac can significantly decrease patient-reported pain in the early postoperative period following subpectoral augmentation. It also demonstrates, however, that there is an increased requirement for narcotics between 1-3 days after surgery. These findings suggest that intraoperative administration of analgesics into the implant pocket may thus facilitate an early postoperative recovery; yet, patients should be advised that they might require more pain medication at home for the first few days.

Sensory Loss of Upper Inner Arm and Nipple after Transaxillary and Periareolar Augmentation Mammaplasty - MDbP204

Purpose: Transaxillary and periareolar incision in augmentation mammaplasty has risks of injury to branches of intercostal nerves that lead to sensory loss of upper inner arm and nipple. The aim of study was to compare the incidence of sensory loss between two groups according to incision method. Methods: One hundred seventy one cases that received transaxillary or periareolar subpectoral breast augmentation at the M.D. Clinic from Jan. 2006 to Jul. 2007 were evaluated for sensory loss of upper inner arm and nipple. The cases were divided into transaxillary (118 cases, 69%) and periareolar group (53 cases, 31%). The type of sensory loss was divided into temporary and permanent. The postoperative follow-up periods were from 7 to 22 months (mean: 8.5 months). Results: In cases of upper inner arm, results were as follows; temporary sensory loss in 9 cases (7.6%) and permanent in 2 cases (1.7%) in the transaxillary incision group and, temporary sensory loss in 1 case (1.9%) and no permanent sensory loss in the periareolar incision group. There is no statistical difference between the two groups for permanent sensory loss (P=0.340). In cases of nipples, results were as follows; temporary sensory loss in 26 cases (22%) and permanent sensory loss in 12 cases (10.2%) in the transaxillary incision group, and temporary sensory loss in 12 cases (10.2%) and permanent sensory loss in 3 cases (5.7%) in the periareolar incision group. There was no statistical difference between two groups (P=0.335). Conclusion: There was no statistical difference in sensory loss of upper arm and nipple between transaxillary and periareolar approach after subpectoral augmentation mammaplasty.

Outcome Assessment of Breast Distortion Following Submuscular Breast Augmentation

Animation deformity or breast distortion during pectoralis muscle contraction following subpectoral breast augmentation is a known entity, but its prevalence and significance remain unclear. The purpose of this study was to identify the incidence and severity of animation deformity as well as its effect on patient satisfaction and interference with certain activities. All procedures were performed by the senior author using a variation of a previously described dual-plane technique. The first part of this study was an evaluation of breast distortion by a group of independent observers in a series of 40 consecutive patients who underwent primary subpectoral breast augmentation. The second part of the study was a questionnaire sent to 195 consecutive patients asking about overall satisfaction, degree of animation deformity, and whether there was interference with any activities. Of the 40 patients' photographs that were evaluated, 9 (22.5%) had no distortion, 25 (62.5%) had minimal distortion, 4 (10%) had moderate distortion, and 2 (5%) had severe distortion. Of the 195 questionnaires, there were 69 responses, a 35% response rate. Fifty-six (82%) described mild to no distortion, 7 (10%) were moderate, and 5 (7%) were severe. According to the survey, the most common activities that were problematic were lifting weights and exercising (24 and 19%, respectively). Only one (1%) patient stated that she would not recommend subpectoral positioning. Although animation deformities do exist, nearly all patients in this study would still choose subpectoral positioning. Patients who may be better candidates for subglandular placement are those for whom exercise is central to their daily living. As a result of this study, surgeons and patients should have more accurate and reliable information regarding the significance of animation deformity after subpectoral breast augmentation.

Combined Preoperative Use of Celecoxib and Gabapentin in the Management of Postoperative Pain

In 2005 we reported a study on the efficacy of the preoperative use of the selective COX-2 inhibitor celecoxib (Celebrex) for reducing both postoperative pain and opioid requirements in patients undergoing bilateral subpectoral breast augmentation. Our findings showed that patients who received 400 mg of celecoxib 30 min before surgery required significantly less postoperative opioid analgesics compared with those given a placebo. Gabapentin (Neurontin) is an agent commonly used to control neuropathic pain. Here we describe a prospective study assessing the efficacy of preoperative gabapentin in combination with celecoxib for reducing postoperative pain and opioid requirements in elective subpectoral breast augmentation. One hundred eighteen patients were given 1200 mg of gabapentin and 400 mg of celecoxib 30-60 min before surgery. From the day of surgery until postoperative day 5, patients documented any use of analgesics and recorded their degree of pain. Results were then compared with those of our previous study in which only celecoxib was used. The combination of gabapentin and celecoxib was found to be significantly superior (p < 0.001) in reducing postoperative pain and opioid requirements than celecoxib alone in the management of postoperative pain and opioid requirements. To decrease postoperative opioid requirements, we recommend 400 mg of celecoxib and 1200 mg of gabapentin taken 30-60 min before surgery by patients undergoing subpectoral breast augmentation or a comparable plastic surgery procedure.

Subfascial Breast Augmentations

Sir: We read the communication by Araco et al. with interest. The authors, four surgeons operating at hospitals in Rome, Italy, and Birmingham, United Kingdom, report on 511 subfascial breast augmentations with “no capsular contracture” and “no rippling.” Such a statistic is most astonishing. It raises several questions that, unless answered, render such a report not only impossible to understand but also unacceptable. The authors suggest that subfascial breast augmentation eliminates capsular contracture and rippling. However, they do not state what criteria they use for capsular contracture and whether or not they used controls. Had any of the four surgeons used similar techniques in comparable patient populations with standard subglandular or subpectoral breast augmentation? If so, what were their incidences of capsular contracture and rippling? Did the authors utilize any criteria in their patient selection, and in particular, did they consider the thickness of the subcutaneous tissue as an important factor? In other words, did they obtain contracture-free and ripple-free outcomes whether or not the patient was extremely thin or overweight (i.e., had a low or high body mass index)? In our own experience, we have found that the thickness of the breast’s subcutaneous tissue is most critical in reducing rippling when saline implants are placed under the glandular tissue.1 The authors also make no mention of the type of implant used, whether the implants were smooth or textured, or whether they were filled with saline or silicone gel. The authors claim that the pectoralis major “fascia is easily dissected as a continuous layer from the muscle” and that it consists of “a thin, strong layer.” Our own findings indicate the opposite.2 We have uniformly found that the fascia covering the lower half of the pectoralis major muscle cannot be dissected as a continuous and intact layer. No matter how gently or slowly we proceeded under 3.5 magnification loupes, this layer proved to be very thin and poorly defined, resisting elevation as a continuous sheet unless we included some of the underlying muscle fibers.2 The authors state that by using a “monopolar” coagulator with a “very thin tip” they avoided damage to the fascia that is otherwise caused by the generated heat. This raises the question of how “undamaged” the fascia is under these circumstances as compared with sharp dissection, in which no thermal injury is present. They also state that “a vigorous traction upward is necessary to cut the muscle fibers closely.” They remark that this step helps in visualizing “small blood vessels.” This statement conveys the message that a layer of muscular fibers is included in their elevation of the pectoralis fascia. Therefore, the authors seem to agree with our comments that it is impossible to elevate the pectoralis fascia in at least the lower half of the pectoralis muscle as a continuous and intact structure. Perhaps it is also for this reason they utilize “compression” to control “small capillaries.” These statements echo our own observations that the dissection of the fascia as a continuous layer, at least in its lower half, is not only impossible but also bloody, since to elevate the fascia, “one must also remove fibers of the underlying pectoralis major muscle,” as we have previously reported.2 This study raises more questions than it answers. Unless these questions are answered, it is impossible, in our opinion, to conclude that “subfascial” breast augmentation has any merit whatsoever.3 Alan A. Parsa, M.D. Seton Hall University Saint Francis Medical Center Trenton, N.J. Andrew Hsu, M.D. Department of Surgery Northwestern Memorial Hospital Chicago, Ill. Kevin Lye, M.D. Fereydoun Don Parsa, M.D. Department of Surgery Plastic Surgery Division University of Hawaii John A. Burns School of Medicine Honolulu, Hawaii

Subpectoral Breast Augmentation Through the Abdominoplasty Incision

Abdominoplasty and breast augmentation are often performed together, and subglandular augmentation through the abdominoplasty incision has been previously described. Nine cases of subpectoral breast augmentation and abdominoplasty performed through a single low transverse abdominal incision were performed between 2002 and 2005. The selection criteria included women who were healthy, nonsmokers, without true breast ptosis or breast deformity requiring additional shaping. The subpectoral space was accessed and the pectoralis major origins were mobilized under direct vision, and the implant pocket was shaped with the aid of a breast sizer and breast dissector. The mean follow-up was 22 months. The surgical goals were realized in all cases, with no asymmetry or implant-related complications. The standard abdominoplasty incision provides ample exposure for the creation of a subpectoral pocket and precise placement of implants. The procedure should be considered in patients who wish abdominal recontouring and breast augmentation and have minimal ptosis.

A Ten-Year Evaluation Following Corrections of Implant Ptosis Subsequent to Transaxillary Subpectoral Breast Augmentation

A Ten-Year Evaluation Following Corrections of Implant Ptosis Subsequent to Transaxillary Subpectoral Breast Augmentation