DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Bilateral micromastia and request for cosmetic breast augmentation.
POSTOPERATIVE DIAGNOSIS: Bilateral micromastia and request for cosmetic breast augmentation.
PROCEDURE PERFORMED: Bilateral breast augmentation with silicone-filled breast implants, Allergan Corporation, Style 15, Natrelle, 304 mL, one per side, placed in submuscular positions via inframammary incisions.
ANESTHESIA: General via endotracheal and 1% lidocaine solution with epinephrine, 10 mL total for local skin incision, and 0.25% Marcaine solution with epinephrine 20 mL, 10 mL per side, for local intercostal and parasternal nerve blocks.
COMPLICATIONS: None.
BLOOD LOSS: Minimal.
SPECIMENS: None.
INDICATIONS: The patient is a pleasant (XX)-year-old Hispanic female who requested bilateral breast augmentation. She was scheduled for and underwent on MM/DD/YYYY bilateral breast augmentation of silicone-filled breast implants placed in submuscular positions via inframammary incisions.
DESCRIPTION OF PROCEDURE: The patient was marked preoperatively for bilateral breast augmentation. This included the inframammary folds and adjustments were made in anticipation of the volume anticipated. Preoperative asymmetries were again discussed with the patient, namely that the left side was slightly larger than the right. This may translate into postoperative asymmetry, and again, this was discussed quite extensively in her preoperative visit. Otherwise, other topographic marks were made on the patient’s chest.
She was then taken to the operating room for bilateral breast augmentation. She was given uneventful general endotracheal anesthesia. Prior to induction, sequential compression devices were placed. Knees were flexed at 5 to 10 degrees. Arms were well padded and outstretched to 90 degrees. Anesthesia assisted with checking the positioning.
The proposed inframammary incisions were first cleansed with Betadine and then 10 mL total of 1% lidocaine solution with epinephrine was used for local infiltration. After this was done, the anterior chest was prepped and draped with ChloraPrep solution. The patient was prepped and draped as already described.
The procedure began on the right side. The inframammary incision was made with a 15 scalpel blade. This approximated 6 cm. The skin incision was taken down with the Bovie device through the glandular breast tissue. Care was taken to withdraw on the glandular breast tissue anteriorly to prevent any inadvertent lowering of the inframammary fold.
Ultimately, dissection continued onto the pectoralis major muscle. The submuscular pocket was developed in a sequential and precise fashion. The pectoralis major muscle was taken off the costal attachments approximately 1 cm above the inframammary fold. Submuscular pocket was then developed and swept very carefully.
The interface between the pectoralis major, minor and serratus anterior muscles was then taken down under direct visualization. Perforators were taken down under direct visualization as well with a prospective hemostasis approach. The sternal attachments were left in place but attenuated where appropriate.
Accessory origins of the pectoralis major were taken down as necessary. After the submuscular pocket was made precisely with the preoperative planning, a sizer was used to gauge the pocket exposure. Final adjustments were made and it was felt it would be best to accommodate around a 304 mL implant, which was what she wished preoperatively.
The soft tissue bed was made hemostatic with the electrocautery device. The soft tissue bed was also cleansed with antibiotic irrigation solution. After this was done, the sutures were left in place. In an identical fashion, the left, again the inframammary incision was made and the subpectoral pocket was developed in an identical fashion. Perforators were taken down under direct visualization. The costal attachments of the pectoralis major muscle were taken down approximately 1 cm above the inframammary fold and the interface between the pectoralis major, minor and serratus muscles was developed cleanly. Again, the pocket dissection was done precisely. The sizer was used on this side as well and final adjustments were made at this point.
With both pockets developed, attention was drawn back to the right side. Marcaine 0.25% solution with epinephrine was used, 10 mL on each side for local intercostal and parasternal nerve blocks. Again, the 10 mL syringe was withdrawn prior to injection to prevent any intravascular entrance and there was none. After this was done, the soft tissue bed was again further cleansed and made hemostatic and checked for hemostasis. Tegaderm was applied on the surgical incision and a small cutaneous window was made. Then, 2-0 Vicryl sutures were placed, but not tied down.
Using a no-touch technique, new sterile instruments and surgical gloves were used as well, and ultimately, a Style 15 Natrelle silicone-filled breast implant, Allergan Corporation, 304 mL, was inserted into the submuscular pocket using a no-touch technique. The implant was immediately doused in a triple antibiotic admixture including 500 mL normal saline, 1 gram Ancef, 50,000 units of bacitracin and 80 mg of gentamicin. This triple antibiotic admixture was used to cleanse the implant. The implant was then inserted. Posterior orientation tab was checked. Then, the 2-0 Vicryl sutures were tied down. Ultimately, then 3-0 and 4-0 Monocryl sutures were used in more superficial and subcuticular layers for further coaptation. There was nice approximation without excessive tension identified.
Prior to final closure, the left implant was placed. Again, the implant was doused in a triple antibiotic admixture using new sterile instruments and surgical gloves. The implant was inserted using a no-touch technique with a cutaneous window and Tegaderm with a 2-0 Vicryl sutures already preplaced. Posterior orientation tab was checked. Final adjustments were made with the patient in the near 90 degrees position at numerous times to assist with size and symmetry. The sutures were then tied down and the closure was performed.
Again, sponge and instrument counts were checked at numerous times and were correct. No immediate complications were identified. On the surgical incision, Steri-Strips were applied. She was then placed in a surgical bra. She was taken to the recovery room in good condition with no immediate complications identified. In summary, the patient underwent bilateral breast augmentation using silicone breast implants via inframammary incisions. She tolerated these procedures quite well without immediate complications.
