JAIME ANGER, MDPortuguese

BREAST AUGMENTATION WITH SILICONE GEL PROSTHESIS THROUGH THE AXXILARY APPROACH

    Dr. Jaime Anger was one of the first to perform this technique in Brazil in 1987.

    In order to better understanding of this type of procedure, we present  the summary of Dr. Anger's presentation in the Brazilian  Plastic Surgery Annual Meeting in 1995 when he wan the price  "Georges Arié" given to the best scientific presentation in breast surgery. This was the first report of the use of Videsocopy in Sub-Muscular Breast Augmentation. After 2002 the author reported the use of ultrasonic scalpel to muscle release improving the result in the sub-muscular axilay approach..

    The use of prosthesis in breast surgery is well defined in Plastic Surgery. It is used for breast augmentation, in breast reconstruction after cancer treatment and also when is necessary to remove a grear amount of breast tissue in breast dysplasia. Many types of materials were used to enlarge the breast. The main revolution occurred in 1962, when CRONIN reported the use of silicone breast prosthesis.

    The first devices were composed by an silicone envelope with dacron sponge inside. Many modifications were done since than. The envelope is thinner and the sponge was changed by silicone gel. The result was a more natural shape and texture very close to a normal breast. Nowadays two types of envelopes are used: smooth and textured. The indication depends on the anatomical positioning of the prosthesis and the tissue reaction. The prosthesis may have silicone gel inside or can be filled with saline. There is also inflatable devices with two chambers, containing silicone gel in one of them. (Becker prosthesis)

    Up to the technological modifications of the devices and the improving of the surgical technique the amount of complications is falling every year. Capsule formation around the silicone prosthesis is now less then 2%.

    The most common complain is still the resulting scar. The position and the dimensions of the scar depends on the access route and the size and type of prosthesis used.

    We prefer to use techniques that avoid inside breast tissue routes. The  surgical procedures that cut the breast tissue may disrupt the mammary ducts and promote scars inside the breast tissue that may facilitate port-operative infection, bleeding and capsule formation. The incision can be placed in the middle of the areola or in the inferior border of the areola complex.

    The transumbelical route doesn't allow us to use gel prosthesis. We have also the option to introduce breast implants through the abdominal incision when a abdominal dermolipectomy is combined.

    The sub-mammary fold and the axxilary routes are the preferred.  Sometimes the sub-mammarury fold scar may be visible and represents a stigma.

    The axxilary approach is the most aesthetic procedure and the scar is always less visible. Otherwise is technically very difficult to perform and depends on the surgeon's experience. The procedure is based in a intra-axxilary horizontal incision just inside the hair area. The incision is choosed inside a natural fold. Through this incision is dissected the pocket where the implant will remain. Prosthesis up to 350 cc volume can be easily introduced through this small 3 cm incisions.

    In our initial clinical experience between 1988 and 1993, with 54 cases the complete success was achieved in 46 patients. In 2 patient was necessary to change the implants following hard capsule formation. 8 cases presented breast asymmetry.

    In 1993 a true revolution occurred in this technique after the introduction of videoscopy to improve the borders dissection. This technique is based in the use of a 10 mm TV microcamara passed by the incision allowing a perfect vision. The image is projected in a TV screen. It is possible to identify any bleeding and to perform a perfect dissection with details of the pocket contour resulting in a complete breast simetry.

    The implant can be positioned in front of or beneath the pectoralis major muscle. We prefer the sub-muscular approach up to make easier the breast cancer diagnosis. The sub-muscular positioning results in more aesthetic and natural result impairing the breast border vision that is a common think when the prosthesis is placed in front of muscle. This position helps to prevent fibrous capsule formation up to the massage performed by the muscle movement.

    From 1993 to 2003,  182 surgeries were performed, 175 obtained a good result. 3 patients presented fibrous capsule reaction and was necessary to change the implant. 2 of them through the same axillary incisions.

    After 1999 Dr. Jaime Anger is using laser equipment or ultrasonic scalpel to dissect the tissues. These new techniques help to minimize the surgical complications and to improve the final result

Augustr, 18,  2006