Operative Technique in Plastic Surgery – Kevin C.Chung

52
CHAPTER
Babysitter Nerves for Facial
Reanimation
Adel Y. Fattah
DEFINITION
■ The aim of facial reanimation is to provide facial symmetry at rest and
synchronized coordinated facial expression.
■ When the facial nerve is unusable but facial musculature is intact,
reinnervation is preferred.
■ Cross face nerve grafting (XFNG) allows for the contralateral facial nerve to
direct its activity to the paralyzed side.
■ The main issue for this technique is the long period of time for nerve
regeneration to occur along the graft. This results in irreversible muscle
atrophy unless the grafts are performed soon after initial denervation, as it
typically takes 6 to 12 months for axons to reach their target muscle.
■ In addition to the axon growth, there is a degree of axonal “dropout,” as
regenerating axons fail to complete their journey along the full length of the
graft affecting clinical outcomes.1,2
■ To overcome this, the babysitter procedure was introduced to provide a rapid
reinnervation to the muscle while awaiting nerve growth across these long
grafts.3
■ The term babysitting in its original context is used to describe the
maintenance of viable musculature while waiting for the cross face nerve
grafts to grow and reinnervate the musculature to achieve spontaneous
animation.
■ Since its inception using the hypoglossal nerve, the principle has developed,
and other cranial nerves have been used to babysit the facial musculature such
as the motor nerve to masseter.4

■ The author has exclusively used the masseter nerve because there is less
morbidity.
■ There is little or no functional deficit produced by using the motor nerve to
masseter as a donor. By contrast, hypoglossal nerve sacrifice can result in
issues with speech and swallowing, even in the minihypoglossal transfer.
■ There is no synkinesis with tongue movement; there is some with chewing,
but this abates with training.
■ There is no need for interposition grafts of sural or greater auricular nerves
with their own donor sensory deficits. Additionally, axons will only have to
cross one neurorrhaphy, which reduces time to reinnervation.
■ To combat the axonal dropout in XFNG, another form of babysitting may be
used.
■ This involves the coaptation of an end-to-side sensory nerve to the cross face
nerve graft at a point along its length to provide a source of neurotrophic
factors to encourage axonal growth toward the target.5
■ Therefore, reanimation of the paralyzed face can be optimized by using a
motor nerve to babysit the musculature and sensory nerves to babysit the cross
face nerve graft.
■ In this chapter, the author will describe the preparation of the motor nerve to
masseter and its transfer to the ipsilateral facial nerve to babysit the facial
musculature. The sensory babysitting of the cross face nerve graft will also be
described.
ANATOMY
■ The masseter muscle is one of the muscles of mastication.
■ It arises from the lower border and medial surface of the zygomatic arch and
inserts into the lateral surface of the mandible.
■ The muscle consists of three layers—superficial, middle, and deep (FIG 1).
■ The superficial muscle fibers pass backward and downward, and the deeper
fibers are more vertical. The motor nerve to masseter is derived from the
mandibular division of the trigeminal nerve. It leaves the infratemporal fossa
by passing over the lateral pterygoid muscle and mandibular notch. It enters
the masseter muscle from its deep surface and courses down between its deep
and middle layers having a diameter of 1 to 2 mm. It becomes more
superficial distally toward the anterior inferior part of the muscle and runs
alongside the (friable) vascular pedicle that arises from the inferior alveolar
artery. Proximally, within the muscle, it gives a number of small short

branches, but it typically has one or two significant branches, one longer than
the other, that can yield 2 to 3 cm of useful nerve before terminal
branching.6–8
FIG 1 • A. Topography of the motor nerve to masseter.
The main trunk typically divides into a long posterior
branch and a shorter anterior superior branch. B. The
nerve (N) lies deep in the muscle, which comprises
superficial (s), middle (m), and deep (d) portions.
■ The facial nerve exits the stylomastoid foramen, turns superficially, and
immediately enters the substance of the parotid gland where it is classically
described as dividing into five branches—temporal (frontal), zygomatic,
buccal, mandibular, and cervical.
■ The nerve usually divides into upper (temporal) and lower (cervical) trunks at
first, from which these branches arise. In practice, they comprise five variably
interconnected groups of branches hereafter referred to as divisions.
■ Despite the various studies of facial nerve anatomy, it may be more useful to
envision the facial nerve as consisting of physiological and functional
divisions that do not necessarily correlate to the anatomic distribution of
branches but instead relate to muscular groups and actions.
■ The temporal branch of the facial nerve exits from the upper pole of the

parotid gland at the level of the zygomatic arch and becomes superficial being
plastered onto the underside of the temporoparietal fascia.
■ The course of the nerve follows a line drawn from 0.5 cm below the tragus to
1.5 cm above the eyebrow, but 3D modeling demonstrates that the branches
cover a triangular area bordered between a line through the palpable
zygomaticofrontal and zygomaticotemporal sutures and a vertical line 1 cm in
front of the auditory meatus.9 At the lateral margin of frontalis, these branches
run deep to frontalis and orbicularis oculi (which it innervates), eventually
reaching the glabella region to supply the depressors of the brow.
■ The zygomatic division leaves the parotid gland to run just inferior the
zygomatic arch immediately deep to the superficial musculoaponeurotic
system (SMAS) to innervate the elevators of the upper lip and lower portion of
orbicularis oculi.
■ Distally, it runs on the undersurface of the zygomaticus muscle complex
before ramifying more medially in the face. The buccal branches exit the
anterior border of the parotid gland and run inferior to the parotid duct and on
the surface of the buccal fat pad deep to the SMAS layer to supply the
muscles of the mouth and cheek.
■ Both zygomatic and buccal divisions have a highly overlapping distribution
of innervation that allows transection of one or more branches without
weakness; this is the basis of XFNG.
■ The mandibular branch leaves the lower portion of the parotid gland and
swings down below the ramus of the mandible to supply the muscles of the lip
and chin.
■ Cadaveric dissections demonstrate that the nerve always comprises at least
three major branches that run on the undersurface of the platysma and
superficial to the facial vessels.10
PATHOGENESIS
■ A nerve injury that is significant enough to damage the axon leads to Wallerian
degeneration. It takes around 72 hours for the process to become established to
the point that nerve conduction fails.
■ One method of determining such axonotmesis vs neurapraxia is to
demonstrate conduction in the peripheral nerve segment. When there is no
regrowth of axons distally, the end organs eventually undergo irreversible
changes, which hinder muscle recovery from prolonged denervation.11
■ The quality of the recovery following repair depends chiefly on the number

of axons that successfully reach their correct targets and the subsequent
myelination of these axons.
■ Therefore, treatment is best achieved by reinnervating the end organ as
effectively as possible, specifically delivering as many axons as soon as
possible to the end organ.
■ As well as changes in the muscles, nerves that are chronically denervated (ie,
have suffered axonotmesis) undergo changes proximally; the myelin sheaths
collapse with reductions in conduction velocity and changes in the cell bodies.
■ Long nerve grafts such as XFNGs also suffer chronic denervation changes
reducing the capacity for nerve regeneration. Donor axons from sensory
nerves can protect nerve grafts from chronic denervation and thereby improve
axonal growth through the graft.5 Such protection of chronically denervated
nerves improves regeneration due to endogenous trophic support.12
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The most important factor in the history is determining the premorbid status of
facial animation and time since the injury as this will determine the presence of
viable facial musculature that may act as a target for reinnervation.
■ In general, the sooner innervation is re-established, the greater the likelihood
of a better functional outcome.
■ Most clinicians would suggest that reinnervation of musculature is attempted
within 12 to 24 months of injury. Thereafter, results may be unpredictable.
■ The examination is directed toward muscle-specific objectives and determines
the presence of intact donor nerves. Therefore, examination of the facial nerve
of the affected side should delineate that the deficit one is attempting to
reconstruct.
■ Muscle-specific treatment goals include brow elevation, eyelid closure,
smile, and lower lip function.
■ Cranial nerve examination is performed specifically looking for donor nerve
activity, such as contralateral facial nerve function (examining each division)
and activity of the muscles of mastication.
■ Palpate the cheek and feel for the presence and power of masseter and
temporalis contraction to determine innervation.
■ Examination of the tongue is performed for deviation that will indicate
hypoglossal nerve activity.
SURGICAL MANAGEMENT

■ General management of facial palsy has been published in detail elsewhere,13
but the principles of reanimation remain: the re-establishment of movement, for
which the muscle is required with a nerve to control that motor function.
■ Soon after facial nerve injury, the muscle remains intact for a short time, and
reinnervation of this can yield good results.
■ Once the native muscle has atrophied, new muscle will need to be imported
to re-establish the muscle-specific functions outlined above.
■ The key points to evaluate are the presence of a functioning proximal nerve
stump (mainly based on the history) and the time elapsed after the injury (that
will indicate the likelihood of functioning facial musculature).
■ By definition, the requirement for a cranial nerve transfer (babysitter)
intimates that a proximal nerve stump is unavailable (FIG 2).
Preoperative Planning
■ Preoperative planning is informed by clinical examination as outlined above.
■ Electrical conduction studies are useful if there is debate over the presence of
viable facial musculature, but it is generally not used after 1 year because after
18 to 24 months after injury, the likelihood of adequate active muscle sufficient
for reconstruction is low.
Positioning
■ The patient is positioned supine on the operating table with a shoulder roll to
extend the neck and a head ring to support the head that is rotated to the
opposite side (FIG 3).

FIG 3 • A. Lines are restricted to one side of the patient
to allow access to the anesthesiologist without the
surgical team obstructing. a, arterial line; w, warming
blanket; uc, urinary catheter; t, temperature probe; v,
ventilation circuit; To, tourniquet; EKG, EKG leads. B.
Tarsorrhaphy using polypropylene suture through the
gray line of the eyelid is used to avoid corneal
exposure. The tube is positioned to the side away from
the proposed intraoral incision. C. The head is
positioned on a head ring with a shoulder roll providing
neck extension. Not shown: the legs are prepared to
allow a full range of movement below the knee; a sterile
tourniquet is also applied.
■ An orotracheal intubation is performed with a “south-facing” tube that is
neatly taped in the midline to maintain as much symmetry as possible. This is

to allow the movements of the face to be observed during neurostimulation of
the donor facial nerve and easy access to the upper buccal sulcus for access to
the graft if required.
■ The face is infiltrated with a 1:400 000 solution of adrenaline prior to
preparation and draping to allow adrenaline time to work.
■ Local anesthesia is not used to permit nerve stimulation; likewise, the
anesthesiologist should be aware to avoid intraoperative paralysis.
■ Typically, 20 to 50 mL of infiltration is used; the volume should be sufficient
to facilitate hydrodissection of the skin flap.
FIG 2 • Flowchart summarizing options for facial nerve
reconstruction without an ipsilateral proximal stump.
Native muscle reinnervation is preferred for early
reconstruction, whereas the muscle will need to be
imported in later cases. Such muscle may then be
innervated by contralateral facial nerve (XFNG) or
cranial nerve transfer.
■ The face is prepared with aqueous povidone-iodine solution, and the mouth is
also prepared.
■ A throat pack is inserted, and the head is draped in a turban fashion with the
ears exposed.
■ If a sural nerve harvest is to be performed, access to one or both legs must be
unhindered: a U or W drape is used, and the whole leg is prepared to allow the

legs to be maneuvered to afford access for sural nerve harvest.
■ A sterile tourniquet is applied to the thigh.
■ In a unilateral case (eg, V–VII transfer only), lines and blood pressure
monitoring equipment are connected to the contralateral side, and the table is
positioned so that the surgical team is on one side and the anesthetic team has
unfettered access to the other.
■ A urinary catheter is inserted and removed at the end of the case.
■ In long cases, such as cranial nerve transfer with free gracilis flap harvest or
use of multiple XFNGs, tarsorrhaphies are performed to protect the cornea.
■ A pressure-reducing mattress is advised with repositioning of the patient
partway through the procedure to ensure that pressure areas are not at risk.
This involves the team shifting the body weight from one hip/shoulder to the
other with minimal disturbance to the position of the surgical field.
Approach
■ For XFNG and masseter nerve transfer, the approach to the face is via a
modified facelift incision.
■ The full length of the incision runs from 1 to 2 cm above the zygomatic arch,
along the anterior border of the root of the helix, down the edge of the tragus,
and at the lobule of the ear, curves behind the angle of the mandible.
■ Traditionally, this incision extends downward toward the neck in the manner
of a parotidectomy incision.
T E C H N I Q U E S
■ Exposure of the Facial Nerve
■ In most XFNG procedures, sufficient access is gained to identify the donor
facial nerve and motor nerve to masseter by using the preauricular portion of
the incision alone (TECH FIG 1A).
■ If further access is required, the incision is taken behind the ear lobe and
then down along the anterior border of sternomastoid.
■ Prior to infiltration, a point midway between the root of the helix and the
commissure of the mouth is marked.
■ This corresponds to “Zuker point,” a landmark for the position for the

zygomatic/buccal branches that animate the smile (TECH FIG 1B).
■ The upper portion of the incision is marked as a soft curve parallel to the
curve of the helical margin, and as the tragus is approached, the incision is
carried into the fossa immediately above the tragus; here, a right-angle
change in the direction of the incision is made to help align the skin for
closure.
■ Thereafter, the incision is carried along the “edge” of the tragus, and at the
incisura (between tragus and antitragus), another perpendicular change of
direction is made anteriorly and then inferiorly to run along the crease
between the anterior lobule and cheek.
■ The right-angle changes of direction will counteract the tendency of scar
contraction to create an indistinct tragal contour.
■ The lower part of the incision is then carried inferior and behind the lobule
just outside of the natural crease. Placing the incision in the crease effaces
this natural landmark.
■ The skin incision is made with the blade just through the dermis; then, the
blade is turned forward, and the skin is lifted anteriorly for a few millimeters.

TECH FIG 1 • A. Incision required for access to the
facial nerve. Note that the right-angle turns above and
below the tragus. B. Markings for the facial nerve
dissection midway between the root of the helix and
the oral commissure. X indicates the Zuker point. C.
Raising of the skin flap. While the assistant holds
retractors, the operating surgeon places traction on
the skin with the middle finger and on the SMAS with
the thumb. D. Forceps point to the exposed facial
nerve.
■ Immediately superior to the tragus, the subcutaneous plane over the SMAS
is easiest to enter, dissection proceeds here, and once anterior to the tragus,
the facelift flap can be lifted off the tragus safely in a retrograde direction.
■ Thereafter, most of the dissection is continued with Bovie monopolar
cautery.
■ Careful skin traction with the left hand allows rapid dissection anteriorly
until the anterior border of the parotid gland is reached; this is usually just
proximal to the Zuker point (TECH FIG 1C).
■ Here, the SMAS becomes noticeably thinner and monopolar that is
switched for scissor dissection.
■ Using a careful spreading motion with the scissors, the sub-SMAS plane is
entered, and the speed of dissection is slowed for identification of facial
nerve branches (TECH FIG 1D).
■ The facial nerve branches sit on the surface of the buccal fat pad, and
neurostimulation with a bipolar stimulator (Neurosign 100, Spring

Gardens, UK) may be used to discern between ligamentous structures and
functioning facial nerve branches.
• Once facial nerve branches are identified, they are then dissected
retrogradely into the parotid gland to find branches that will match the size
of the donor nerve.
■ Nerves to be used as recipients for transfer are prepared and tagged with
microsuture material but are not divided to ensure ease of location at the time
of neurorrhaphy.
■ Exposure of the Motor Nerve to Masseter
■ Once the facelift flap has been raised and facial nerve dissection completed,
attention is turned to the donor nerve.
■ The point at which the nerve can be found is 1 cm below the lower border
of the zygomatic arch 3 cm anterior to the tragus (TECH FIG 2A).
■ At this point, an incision is made in the parotid fascia that is parallel to the
facial nerve branches and is approximately 2 cm long.
■ Dissection is performed slowly with meticulous hemostasis, as bleeding
from the multiple tiny vessels in the parotid can make deeper dissection
and visualization of the nerve challenging.
■ As the dissection proceeds through the parotid, spreading scissors parallel
to the direction of the facial nerve minimizes risk of damage with care
taken to identify and protect facial nerve branches.
■ Once the fascia over the masseter muscle is reached, a small amount of blunt
undermining is performed to free the parotid from the underlying muscle and
facilitate retraction.
■ Thereafter, a muscle-splitting dissection is performed through the masseter
muscle.
■ Cautiously and with meticulous hemostasis, the muscle is parted, and small
amounts of muscle fibers are removed as required to create a path to the
deeper muscle.
■ The assistant is vital, retracting with Ragnell or cat’s paw retractors
(TECH FIG 2B).
■ Once a “plane” of tendinous tissue is found, the transition between the
deep and middle layers of the muscle is indicated.
■ At this point, the neurostimulator is used to help guide the dissection.

■ Once the nerve is found, careful dissection is used to dissect it proximally
and distally (TECH FIG 2C).
■ The vessels running alongside are friable and bleed easily. The use of
diathermy near the donor nerve is cautious, and pressure is used to achieve
hemostasis.
■ The nerve is dissected as far as possible proximally, extending the muscle
dissection to facilitate this.
■ Then, distal dissection proceeds.
■ The nerve typically splits into two or three branches, and these are
followed as far as is practicable to create a length of nerve that can be
brought up to the recipient facial nerve.
■ The time taken to free the nerve effectively is repaid later with the ease of
neurorrhaphy.

TECH FIG 2 • A. Markings on the SMAS 3 cm in front
of the tragus and 1 cm below the zygomatic arch
indicate the position of the motor nerve to masseter.
B. The assistant is critical in retracting the muscle
during the fiber-splitting approach to the nerve. The
nerve is seen in focus in the depth of the incision. C.
The proximity of the motor nerve to masseter (white
arrow) to the buccal branch of the facial nerve (black
arrow) is demonstrated. D. Completed neurorrhaphy.
The minimal number of sutures is used, and fibrin glue
is then used to complete coaptation (not shown).
■ Standard neurorrhaphy is performed with the operating microscope.
■ 9/0 nylon microsuture material is used, and either end-to-end or end-to-side
coaptation is utilized.
■ Two or three sutures are used to align the epineurium, and then Tisseel glue
(Baxter Int., USA) is used to complete the neurorrhaphy (TECH FIG 2D).
■ Immediately, before the Tisseel glue is applied, a large-gauge permanent-
colored monofilament suture is placed near the neurorrhaphy to loosely
encircle the nerve.
■ This marks the nerve branch for identification at the second procedure
should a contralateral XFNG needs to be coapted to the ipsilateral facial
nerve for restoration of spontaneous smile.
■ Sensory Babysitter for Cross Face Nerve Graft
■ The technique of XFNG is detailed in Chapter 49. The design and harvest of
the gracilis muscle is described in this chapter.
■ The XFNG is broadly used in two different situations:
■ To be banked near the piriform aperture for connecting to a free muscle
flap at a second procedure (TECH FIG 3A).
■ To be tunneled through to the paralyzed side of the face and banked near
the nonfunctioning facial nerve to be coapted to the distal facial nerves
after a period of babysitting the musculature by the motor nerve to
masseter. This adds contralateral facial nerve input for spontaneity of

movement as well as conscious control by the motor nerve to masseter in
response to bite.
■ A buccal sulcus incision is used as a site of access to allow the nerve to be
tunneled across the face into the contralateral side, or if combined with a
gracilis flap, the neurorrhaphy can be performed via this incision.
■ Additionally, this incision is used to identify a branch of the infraorbital
nerve that can be used as the babysitter for the XFNG.
■ Once the donor branches have been selected, a large hemostat, such as Tudor
Edwards artery forceps (Scala Surgical, London, UK), is used to create a
preperiosteal tunnel to the buccal sulcus.
■ Prior to creating the tunnel, local anesthetic is injected into the mucosa of the
buccal sulcus where the intended incision is to be made to perform the
babysitter neurorrhaphy.
■ Once the tip of the hemostat is seen, it is positioned to reach the contralateral
lip beyond the frenulum.
■ Here, an incision is made with a blade or monopolar diathermy down onto
the hemostat.
■ A silicone loop is attached to the end of the hemostat to ensure the tunnel is
not lost, and attention is turned to developing the buccal sulcus incision.
■ The incision is extended and sited just below the apex of the buccal sulcus
(as one would for a Le Fort I osteotomy) with efforts to avoid crossing the
frenulum.
■ If the nerve is needed as a XFNG to the contralateral facial nerve, a tunnel is
made through to the contralateral face where the damaged facial nerve has
already been exposed and identified. It is banked in a location that is easily
identifiable at a subsequent procedure.
■ It is tacked to the surrounding soft tissue with a large-gauge (4/0 or 3/0)
permanent-colored monofilament suture to allow rapid identification for
the second procedure, which would comprise re-elevation of the facelift
flap identification of the distal facial nerve branches and coaptation in an
end-to-side or end-to-end manner depending on the requirements.
■ Hemostasis in the buccal sulcus is achieved, and a spreading motion with the
tenotomy scissors perpendicular to the direction of the orbicularis fibers is
performed. This will tease out sensory nerves that ramify throughout the
upper lip (TECH FIG 3B).
■ Under ×3.5 loupe magnification, a large branch is selected and carefully

dissected back far enough to reach the XFNG in the buccal sulcus in a
tension-free manner (TECH FIG 3C).
■ The operating microscope is brought in and the field prepared.
■ A wet sponge is placed into the oral cavity to push the tongue back and
create a platform upon which neurorrhaphy can be performed.
■ Microscope background is placed on the swab to facilitate manipulation of
the nerves, and retracting “fishhooks” are used to hold the lip in position.
■ An epineural window is made in the XFNG, and the infraorbital nerve
branch is carefully aligned.
■ The window is adjusted for size match. Once an alignment is achieved, two
or three 9/0 nylon sutures are used to maintain the alignment, and the nerve
is returned into the buccal sulcus incision in the desired position (TECH
FIG 3D).
■ The alignment of the nerves is checked and the neurorrhaphy completed
with Tisseel glue.
■ Once the Tisseel has set, the incision is closed with 5/0 Vicryl Rapide
(Ethicon) in a two-layer watertight fashion: using a running mattress suture in
one direction, locking the knot, and then suturing back on yourself in an
over-and-over fashion to complete the two-layer closure.
■ Once the Tisseel has coagulated (set), the operative field is washed with
copious amounts of warmed saline.
■ The second careful round of hemostasis is performed, and the underside of
the skin flap is also checked.
■ A small suction drain is placed exiting behind the ear.
■ The drain itself is held away from the sites of neurorrhaphy by using a loop
of fast-absorbing suture such as catgut or Vicryl Rapide (Ethicon).
■ Care is taken to position this suture such that it will not hinder removal of
the drain.
■ Key subcuticular sutures using 4/0 undyed Vicryl are placed: upper border of
the tragus, lower border of the tragus, and inferior-most lobule. These serve
to align the skin edges accurately.
■ Thereafter, two or three additional sutures are placed to give strength to the
closure.
■ Intracuticular closure is performed with 4/0 polypropylene in a looped
fashion. This allows for four or five sutures to close the whole incision and
be easily removed in the office at the 10th to 14th postoperative day.

■ Nylon does not “run” as easily as polypropylene and is avoided.
■ Chloramphenicol ointment is applied to the wound margin, and no further
dressings are required.

TECH FIG 3 • A. Cross face nerve graft (arrows)
demonstrated after being tunneled through to the
buccal sulcus. B. The use of the tenotomy scissors to
spread perpendicular to the fibers of orbicularis oris
allows the sensory branches of the infraorbital nerve
to be teased out (white arrow; black arrow indicates
nerve graft). C. The branch is seen more clearly after
further dissection. D. End-to-side coaptation of the
infraorbital nerve branch to the cross face nerve graft.
PEARLS AND PITFALLS

Meticulous
hemostasis
■ Bleeding makes visualization of structures difficult; careful
“bloodless” dissection facilitates ease of dissection.
■ Hematoma of the masseter muscle causes trismus or may
compromise the facelift flap if not treated rapidly.
Hemifacial
microsomia
■ In these instances, the motor nerve to masseter can be small caliber
yet still provide powerful neuronal input.
Incision
placement
along the
tragus
■ Placing the incision along the “edge” of the tragus avoids the bulky
appearance and awkward suturing when closing a retrotragal incision
positioned on the inner surface of the tragus. Additionally, the
assistant should not place skin hooks into the tragus during initial
skin elevation. The delicate skin tears through easily, and adequate
retraction can be achieved by placing a hook in the more robust skin
immediately superior and inferior to the tragus.
Synkinesis
■ Regular surveillance is required to look for and address synkinesis
early.
POSTOPERATIVE CARE
■ Postoperative care revolves around a warm, well-hydrated, and pain-free
patient.
■ The patient has “slow wake-up” to minimize the risk of coughing and
hematoma postoperatively.
■ Postoperative discomfort is largely related to facial swelling; therefore, the
patient is nursed head up to mitigate this cause of the pain.
■ Adequate analgesia and antiemetics are tailored to the patient.
■ Typically, regular acetaminophen (IV until oral intake is achieved) is used
with aliquots of oral morphine to ensure the patient is pain-free. Tylenol or
Percocet can be used upon discharge for adults but are often discontinued by
patients quickly following discharge as the swelling subsides.
■ In children, the absorption of codeine may be unpredictable, and therefore,
oral morphine is recommended to take home.
■ A laxative is initiated following surgery and stopped once the opiate
analgesia is discontinued and normal bowel activity resumed.
■ Longer procedures that involve exposure or tunneling via the oral cavity will
indicate the use of antibiotics for 24 to 48 hours postoperatively.
■ The patient is reviewed the next day and swelling is usually worse; patients are
counseled regarding this preoperatively.
■ The drain is removed the following morning, as drainage is typically

minimal.
■ Significant volumes of drainage for more than a day or so should prompt
consideration of a salivary fistula and request for analysis of drain fluid for
salivary amylase.
■ Soft diet is started on the next day and maintained for 2 weeks; thereafter, a
graded return to full diet is undertaken.
■ In general, the patients may be discharged the following postoperative day if
comfortable and are accompanied.
■ Once movement is detected in the face, facial therapy and rehabilitation are
initiated by an experienced facial physiotherapist.
■ Graded biting exercises are started to teach the patient to learn to control the
degree of facial movement by biting.
■ Mirror therapy is used and the patient given a program of exercises to
perform at home.
■ Regular review and guidance are required to look for synkinesis and to
develop strategies to address this.
OUTCOMES
■ In the few studies to date, masseter to facial nerve transfer has good outcomes
with improvements in oral continence, resting tone, and smile with occasional
spontaneous smile.4,14
■ There is, as yet, no published clinical data on end-to-side sensory nerve
babysitting, and current studies are ongoing.
COMPLICATIONS
■ Poor or unaesthetic scarring may occur, and usual counseling and information
are provided. Infection risk is very low as is incidence of hematoma; patients
are informed about likely that treatments should either occur including return to
theater, washouts, and IV antimicrobial therapy.
■ Salivary fistula and Frey syndrome (gustatory sweating) are rare
complications. Failure of reinnervation is also mentioned to the patients.
■ Synkinesis is common and is minimized by careful evaluation of the nerve
branches and consideration of synergistic movements.
■ It is treated with intensive facial physiotherapy and judicious use of
botulinum toxin in selected cases15; the details are beyond the scope of this
chapter.
■ Persistent trismus may occur and is treated in the standard fashion with warm

packs, stretching exercises using wooden spatulas, and reassurance.
REFERENCES
1. Jacobs JM, Laing JH, Harrison DH. Regeneration through a long nerve graft
used in the correction of facial palsy: a qualitative and quantitative study.
Brain. 1996;119(Pt 1 suppl):271-279.
2. Snyder-Warwick AK, Fattah AY, Zive L, et al. The degree of facial movement
following microvascular muscle transfer in pediatric facial reanimation
depends on donor motor nerve axonal density. Plast Reconstr Surg. 2015;135(2
suppl):370e-381e.
3. Terzis JK, Tzafetta K. The “babysitter” procedure: minihypoglossal to facial
nerve transfer and cross-facial nerve grafting. Plast Reconstr Surg. 2009;123(3
suppl):865-876.
4. Klebuc MJA. Facial reanimation using the masseter-to-facial nerve transfer.
Plast Reconstr Surg. 2011;127(5 suppl):1909-1915.
5. Placheta E, Wood MD, Lafontaine C, et al. Enhancement of facial nerve
motoneuron regeneration through cross-face nerve grafts by adding end-to-side
sensory axons. Plast Reconstr Surg. 2015;135(2 suppl):460-471.
6. Cotrufo S, Hart A, Payne AP, et al. Topographic anatomy of the nerve to
masseter: an anatomical and clinical study. Br J Plast Surg. 2011;64(11
suppl):1424-1429.
7. Klebuc M, Shenaq SM. Donor nerve selection in facial reanimation surgery.
Semin Plast Surg. 2004;18(1 suppl):53-60.
8. Hwang K, Kim YJ, Chung IH, Song YB. Course of the masseteric nerve in
masseter muscle. J Craniofac Surg. 2005;16(2 suppl):197-200.
9. davies JC, Fattah A, Ravichandiran M, et al. Clinically relevant landmarks of
the frontotemporal branch of the facial nerve: a three-dimensional study. Clin
Anat. 2012;25(7 suppl):858-865.
10. Nelson DW, Gingrass RP. Anatomy of the mandibular branches of the facial
nerve. Plast Reconstr Surg. 1979;64(4 suppl):479-482.
11. Fu SY, Gordon T. Contributing factors to poor functional recovery after
delayed nerve repair: prolonged denervation. J Neurosci. 1995;15(5 Pt 2
suppl):3886-3895.
12. Gordon T, Eva P, Borschel G. Delayed peripheral nerve repair: methods,
including surgical “cross-bridging” to promote nerve regeneration. Neural
Regen Res. 2015;10(10 suppl):1540.
13. Fattah A, Borschel GH, Manktelow RT, et al. Facial palsy and reconstruction.

Plast Reconstr Surg. 2012;129(2 suppl):340e-352e.
14. Coombs CJ, Ek EW, Wu T, et al. Masseteric-facial nerve coaptation—an
alternative technique for facial nerve reinnervation. Br J Plast Surg.
2009;62(12 suppl):1580-1588.
15. Filipo R, Spahiu I, Covelli E, et al. Botulinum toxin in the treatment of facial
synkinesis and hyperkinesis. Laryngoscope. 2012;122(2 suppl):266-270.

53
CHAPTER
Gold Weight Insertion for
Upper Eyelid Reanimation
Larissa A. Habib and Brian Marr
DEFINITION
■ Upper eyelid loading with a gold weight is the treatment for paralytic
lagophthalmos causing exposure keratopathy. This is due most commonly to
facial nerve damage following trauma, infection, ischemic event, or tumor.
■ Pure gold is used for its density and to minimize allergic reaction.
■ The weights range from 0.8 to 1.6 g.
ANATOMY
■ The upper and lower eyelid meet at the medial and lateral canthus with the
lateral canthus sitting 2 to 4 mm higher than the medial (FIG 1).
■ The palpebral fissure is approximately 28 to 30 mm in length and 9 to 10 mm
in height.
■ The eyelid anatomy can be divided into anterior and posterior lamellae.
■ The anterior lamella consists of the skin and the orbicularis oculi muscle.
■ The eyelid skin is the thinnest in the body (less than 1 mm). The epidermis
receives its nourishment from a deeper connective tissue layer as it lacks
blood vessels and lymphatics. There is a sparse amount of fat in the preseptal
and preorbital skin and is absent in the pretarsal skin.
■ The orbicularis oculi is loosely adherent to the skin and divided into orbital
and palpebral portions. The palpebral portion is further divided into pretarsal
and preseptal and functions in blinking and voluntary winking. The orbital
portion is for forced closure.
■ The posterior lamella consists of the tarsus and the conjunctiva.
■ The tarsus is composed of dense fibrous tissue. It is approximately 1 mm
thick and provides the structural support of the eyelid. The upper eyelid tarsus

extends from the punctum to the lateral canthus and is 30 mm long and 7 to
10 mm high, with the highest portion being centrally. The lower tarsus ranges
from 3.5 to 5 mm in height. The ciliary border contains meibomian gland
orifices that provide the lipid layer of the tear film. The medial and lateral
ends are attached to the orbital rim by the medial and lateral palpebral
ligaments.
■ The conjunctiva is a nonkeratinized, stratified squamous epithelium that lines
the inside of the eyelids and provides coverage to the sclera.
■ Upper eyelid retractors
■ The levator palpebrae superioris arises at the orbital apex and courses
anteriorly for 40 mm ending in the aponeurosis 10 mm behind the septum. At
this junction, it changes direction to vertical and then inserts inferiorly onto
the lower third of the tarsal plate. In addition, some fibers pass anteriorly to
the eyelid crease.
FIG 1 • External and sagittal section depicting the eyelid
anatomy and the surrounding structures.
■ Mueller muscle originates from the undersurface of the levator at the
muscular aponeurotic junction and then travels between the levator and the
conjunctiva to insert on the superior border of the tarsus. It is innervated by
the sympathetic nervous system.
■ The lower eyelid retractors are fascial extensions of the inferior rectus muscle

originating as the capsulopalpebral fascia. The lower lid retractors insert at the
inferior border of the tarsal plate. A small portion of the lower eyelid retractors
joins with Tenon capsule at the inferior fornix and courses anteriorly to form
the lower lid crease.
■ Blood supply to the eyelids is derived from branches of both the internal and
external carotid arteries.
■ Medially, two palpebral branches (superior and inferior marginal arteries)
arise from the ophthalmic to supply the upper and lower lid. These arteries
then travel horizontally as the marginal arcades, which lie on the tarsal plate
(4 mm from the upper margin and 2 mm from the lower margin).
■ Laterally, the lacrimal artery provides branches to both the upper and lower
lid, which then travel horizontally to anastomose with the marginal arcades.
■ The external carotid contributes through branches of the facial, superficial
temporal, and infraorbital arteries.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Facial paralysis can occur from many causes including tumor, postsurgical,
infection, trauma, idiopathic Bell palsy, and cerebral vascular accidents.
■ Ocular complications can range from superficial punctate keratopathy to
corneal ulcer or even perforation secondary to lagophthalmos.
■ A slit-lamp examination should be performed to assess the cornea.
■ The preoperative evaluation includes a detailed examination of the function of
the levator muscle and the compromised orbicularis.
■ This is crucial in choosing the proper weight to allow patient to open eye
once weight is placed.
IMAGING
■ If the cause of the cranial nerve VII palsy is unknown, then imaging as well as
a complete neurologic examination should be done for diagnosis before
surgical correction is done.
SURGICAL MANAGEMENT
Preoperative Planning
■ The appropriate weight is determined preoperatively by taping the weight onto
the upper eyelid at the medial third of the lid with the patient sitting upright.
■ The appropriate weight should allow for complete closure but prevent ptosis
greater than 2 mm.

Positioning
■ The patient should be erect during testing and supine during surgery.
T E C H N I Q U E S
■ Pretarsal Approach
■ A lid crease incision should be marked preoperatively.
■ In elderly patients with levator dehiscence, the incision can be marked
where the crease should be.
■ Local anesthetic with 1% lidocaine and 1:100 000 epinephrine is injected
into the subcutaneous tissue of the upper eyelid.
■ Skin incision is made in the premarked area using a no. 15 blade.
■ Dissection is carried through the orbicularis to identify the septum.
■ Careful hemostasis is obtained using bipolar cautery.
■ Dissection is carried through the orbicularis down to the superior border of
the tarsus. The pretarsal portion of the orbicularis is then dissected downward
from the tarsus to the eyelash line to create a pocket, taking care to remain at
least 2 mm above eyelid margin (TECH FIG 1A).
■ The appropriate weight is placed over the tarsus just medial to the
midpupillary line and secured with 6-0 silk to the tarsal plate taking care to
avoid going through the conjunctiva (TECH FIG 1B–D).
■ Skin is closed with a running subcuticular stitch secured on either end with a
single interrupted 6-0 chromic (TECH FIG 1E).
TECH FIG 1 • A. After an incision is made in the eyelid

crease, dissection is carried to the tarsal plate and
levator muscle. B. A gold weight is placed on the
tarsus with inferior border 2 mm from lid margin. C,D.
Silk sutures are used to hold the gold weight in place
on the tarsus. E. Subcuticular closure.
■ Postseptal Approach
■ The lid crease incision and local anesthesia are done as above.
■ The septum is incised at the superior border of the tarsus, and the postseptal
fat is retracted superiorly to visualize the underlying levator aponeurosis.
Dissection is carried out superiorly to the muscle fibers of the levator to form
a pocket 2 to 3 mm medial to the medial limbus.
■ The weight is placed, and a temporary suture is made to close the skin and
muscle.
■ Sedation is lightened to allow the patient to sit up and open and close the
eyes to assess for closure.
■ The weight is then secured with one superior stitch to the aponeurosis or to
muscle and two inferior stitches to the aponeurosis just superior to the tarsus
using 6-0 silk.
■ Postseptal fat is then draped over the weight, and the septum is closed with
two or three interrupted 6-0 Vicryl sutures.
■ Skin is then closed with a running subcuticular stitch secured on either end

with a single interrupted 6-0 chromic.
PEARLS AND PITFALLS
Technique
■ The orbicularis oculi does not need a separate closure, and in fact, this
may lead to accentuation of the lid crease.
■ When making the pretarsal pocket, refrain from burrowing too close to
the eyelid margin to avoid disrupting the eyelash follicles and causing
inadvertent eyelash loss.
■ After securing the gold weight, evert the lid to ensure that no sutures
are exposed on the tarsal conjunctival side.
■ Older patients with exceptionally thin eyelid skin may benefit from a
postseptal placement to avoid extrusion at the eyelid margin.
POSTOPERATIVE CARE
■ Antibiotic steroid ointment combination with patch for 48 hours.
■ The ointment should be continued twice a day for a week.
OUTCOMES
■ A retrospective review of 107 patients found that 14% required revision
surgery at a mean time of 11.7 months after primary placement. Indications
included prominent implants in 71%, poor eyelid contour in 67%, and
persistent erythema in 29%.1
■ Rofagha et al.2 found a 10.6% extrusion rate and with Kaplan-Meier analysis
found extrusion rate to be 3% at 12 months, 5% at 24 months, 10% at 5 years,
and 35% at 153 months.
COMPLICATIONS
■ Extrusion of weight
■ Astigmatism (more common with pretarsal placement)3
■ Allergic contact dermatitis
REFERENCES
1. Bladen JC, Norris JH, Malhotra R. Indications and outcomes for revision of
gold weight implants in upper eyelid loading. Br J Ophthalmol.

2012;96(4):485-489.
2. Rofagha S, Seiff SR. Long-term results for the use of gold eyelid load weights
in the management of facial paralysis. Plast Reconstr Surg. 2010;125(1):142-
149.
3. Mavrikakis I, Beckingsale P, Lee E, et al. Changes in corneal topography with
upper eyelid gold weight implants. Ophthal Plast Reconstr Surg.
2006;22(5):331-334.

Operative Techniques in
Plastic Surgery
VOLUME II
Kevin C. Chung, MD, MS
EDITOR-IN-CHIEF
Chief of Hand Surgery, Michigan Medicine
Director, University of Michigan Comprehensive Hand Center
Charles B. G. de Nancrede Professor of Surgery
Professor of Plastic Surgery and Orthopaedic Surgery
Assistant Dean for Faculty Affairs
Associate Director of Global REACH
University of Michigan Medical School
Ann Arbor, Michigan

PART 4
Plastic Surgery of the Breast

(Trang không có chữ)

1
CHAPTER
Section I: Augmentation
Mammoplasty
Transaxillary Breast
Augmentation
Louis L. Strock
DEFINITION
■ Hypomastia. This patient requested that she have a procedure to enlarge her
breasts in a conservative way. She also stated that she preferred to have her
breast implants placed in a way that would allow her to avoid incisions on her
breasts (FIG 1A,B).
ANATOMY
■ To manage the request of this patient, the level and shape of the inframammary
fold (IMF) will be lowered with the aid of endoscopic assistance. The
pectoralis major muscle and overlying fascia will be divided according to
external markings and correlated with internal muscle anatomy.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ This patient is a 34-year-old woman who presented for breast augmentation
after having had three children. She requested that her breasts be enlarged to a
small C cup, with as soft a feel as possible. Her examination was remarkable
for mild asymmetry, thin tissue, and large nipple size. Her breast base width
measurement was 11 cm, and pinch thickness measurements were 1.5 cm
laterally, superiorly, and medially. She was also noted to have extremely large
nipples that she requested to have reduced at the time her breast implants were
placed (FIG 2).

SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative planning centered on the choice of breast implant type in the
context of her aesthetic goals and tissue type. She preferred the feel and
intermediate projection of a Mentor MemoryGel smooth wall, round, moderate
plus profile silicone gel device. Other options considered included the same
device type in moderate and high profile versions, and a moderate height,
moderate projection shaped highly cohesive gel device. She stated preference
of a partial subpectoral plane of placement over a subfascial approach. Incision
choices offered to this patient included inframammary and transaxillary, with
the latter preferred by the patient to attempt to avoid incisions visible on her
breasts. Nipple reduction was requested by the patient, to be performed
following completion of the breast augmentation procedure and access incision
closure.
Equipment
■ A standard HD endoscopic tower and camera are used in this procedure. This
equipment is identical to that used for any subspecialty that utilizes an
endoscopic tower and camera. The endoscope that is preferred is a 10-mm 30-
degree angled scope, that is intended to fit correctly into the Emory Endoscopic
retractor (FIG 3). A cautery handle with a suction end is used, and holds a
cautery tube with a spatulated end. This is the basis for the dissection at the
heart of this procedure. Additionally, 4-prong Freeman skin hooks, 2 mirror
image Agris-Dingman dissectors, a 1-in fiberoptic retractor with suction port,
facelift scissors, and two 1-in short Deaver retractors make up the instrument
set for the procedure.1
Positioning
■ The patient is positioned with the arms out ninety degrees and straightened on
armboards. All equipment, cords, and tubing are directed toward the feet of the
patient in the midline. This allows for ease of transition during the procedure
for device placement on either side. There is adequate separation of the
anesthesia equipment from the head and shoulders of the patient to allow the
surgeon to stand above the shoulder on each side during the endoscopic tissue
release portion of the procedure on each side (FIG 4).

FIG 1 • A,B. Preoperative photos showing thin tissue
patient. She has minimal breast volume, poor
inframammary fold definition, and distinctly large
nipples.
FIG 2 • Frontal markings show plan to lower the
inframammary fold to accommodate dimensions of
device to be used.

FIG 3 • Instrument tray used for the procedure. The
Emory Endoscopic retractor is with paired 10-mm 30-
degree-angled endoscope. The cautery handle has a
suction port in back, and a hub for hollow cautery rods
with spatulated ends. The author prefers mirror image
J-shaped rods, but other variants are available. Four-
prong skin hooks, two mirror image Agris-Dingman
dissectors, two 1-in. Deaver retractors, facelift scissors,
and Adson-Brown forceps complete the set.
FIG 4 • All equipment is positioned at the foot of the
bed, including the endoscopic tower. All cords are kept
in a central position to prevent having to move them
during the procedure, regardless of which side is being
augmented. The patient is positioned with the arms out

at 90 degrees. The endoscopic portion of the procedure
is performed with the surgeon above the shoulder.
Approach
■ The procedure can be performed adequately in this patient with use of
inframammary or transaxillary approaches for incision access. The periareolar
approach is more difficult given the relatively small size of the areola in this
patient. Her thin tissue makes a partial subpectoral, or dual plane, approach
preferred to maximize soft tissue cover over the implants.
T E C H N I Q U E S
■ Incision and Initial Dissection
■ An S-shaped incision was planned, centered in the axillary apex (TECH FIG
1). This incision pattern was selected because it allows for a long functional
length in a patient with a narrow area of hair-bearing skin in the axilla. The
long portion of the incision was marked within the longest existing skin
crease. The anterior extension is placed to stay behind the posterior aspect of
the pectoralis major muscle. This is critical to keep the incision hidden during
recovery. A cross-hatch is made centrally to facilitate skin closure. The
incision is made through the hair-bearing skin to the subcutaneous tissue. The
anterior skin flap is raised in an anterior direction toward the lateral edge of
the pectoralis major muscle. The skin flap is kept thin to avoid entry into the
axillary contents. This helps to avoid damage to the intercostobrachial nerve.
Once the lateral border of the pectoralis major muscle is identified, its fascia
is incised, and the subpectoral space is entered under direct vision. A finger
sweep technique is used to further develop the separation between the
pectoralis major and pectoralis minor muscles.

TECH FIG 1 • In this patient, an S-shaped incision
was planned. This incision design was used due to the
narrow width of the segment of hair-bearing skin. This
design permits a longer functional length to attempt to
minimize potential damage to the device during
placement, and minimize ultimate incision visibility
during recovery.
■ Optical Cavity
■ Once the entry between the incision and the space between the pectoralis
major and minor muscles has been defined, the endoscopic retractor is
introduced. Once correctly positioned, the 10-mm 30-degree-angled
endoscope is brought into the operative field and placed into the retractor
sheath. The camera head on the endoscope is checked for proper orientation,
a critical step to ensure safety with the technique. The suction cautery is then
used to create an optical cavity from the undersurface of the pectoralis major
muscle (TECH FIG 2A). Staying on the undersurface of the muscle allows
for variations in rib cage anatomy to not be a problem. This is performed in a
uniform fashion to create optimal visualization of the pectoralis major muscle
in preparation for the muscle release. The author feels that using the cautery
to create the optical cavity is critical to avoid significant blood staining of
tissues that can otherwise make endoscopic tissue dissection difficult. The
key to this procedure is to avoid bleeding in the tissue pocket! (TECH FIG
2B–D). Though the initial descriptions of this procedure advocated use of the
Agris-Dingman dissectors, the author has found that the occasional bloody

outcome from that approach can be avoided with use of the cautery to create
the optical cavity.2
TECH FIG 2 • A. The endoscopic equipment is used in
a way that ensures proper orientation of the
endoscopic tower. The camera head is checked to
confirm correct alignment and orientation for the
endoscopic dissection. The suction cautery allows for
successful smoke evacuation, vital to correct
endoscopic visualization. B–D. Endoscopic view of the
entry into the subpectoral space. Note areolar plane
and lack of anatomic markings. Orientation on this
right sided dissection is as follows: left is medial, right
is lateral, the rib cage is inferior, and the pectoralis
major muscle is superior. The optical cavity is created
using the cautery off the undersurface of the pectoralis
major muscle. The entire base of the pectoralis major
muscle is dissected to complete creation of the optical
cavity.

■ Pectoralis Major Muscle Release
■ Successful creation of an optical cavity facilitates release of the pectoralis
major muscle. The first step to release of the pectoral muscle is to correlate
internal anatomy with external landmarks. This is the key step to the
technical control needed to control the level and shape of the IMF (TECH
FIG 3A–D). An advantage of the axillary approach is that, when performed
as described, the surgeon has a direct and clear view of the pectoralis major
muscle and fascial layers that cannot be matched with an inframammary
approach. Additionally, the incision itself has no bearing on the IMF or the
level it is placed.
■ In the patient shown, the plan was to lower the IMF. The initial muscle
release is performed to divide the muscle at a level several millimeters above
the existing IMF, medial to lateral, again carefully correlating external
landmarks to internal anatomy. Transillumination can be very helpful in
confirming that the muscle has been divided at the desired level. Once this
has been confirmed, the cautery is used to dissect in a very controlled and
limited fashion in a plane superficial to the lower muscle cuff. Because of the
magnification of the endoscope, limited tissue cuts make powerful and
significant changes in the area of the IMF. Transillumination can again be
used to confirm that the release is to the desired level of the new IMF. The
muscle edges of the upper and lower cuffs are inspected and contacted with
the cautery if any bleeding points are noted. It is of critical importance that
overdissection be avoided! (TECH FIG 3E–G) Additionally, it is critical to
understand that when planning to lower the IMF, the actual release of the
pectoralis major muscle should never be below the existing IMF, as such a
release will consistently result in a double bubble deformity. If the goal is to
maintain the IMF at the same level without change, then the pectoralis major
should be divided at a level 1.5 to 2 cm above the existing IMF. When
properly performed, visual clarity afforded by the endoscope allows for the
prepectoral fascia to be divided or maintained as needed.

TECH FIG 3 • A. The start of the release of the
pectoralis major muscle is based on correlating

external markings with internal anatomy. B,C. The
release level is just above the existing level of the IMF.
The correct level can also confirmed by
transillumination, as shown. D. The completion of the
initial release is shown. E. Transillumination confirms
the IMF level from the initial dissection, and then after
the fold is lowered in a precise manner. The lateral
portion of the tissue pocket is underdissected
intentionally at this stage. F,G. The IMF is lowered by
dissection just superficial to the prepectoral fascia of
the lower muscle cuff. This is shown before (F) and
after (G) the controlled release, performed to match
external markings. Note that small cuts performed in
this way are needed to lower the IMF, and that any
overrelease is difficult to correct with this approach
and should be aggressively avoided! (H). The
adequacy of the periphery of the dissection is checked
with the aid of Agris-Dingmandissectors, placed in a
way to avoid excessive contact with the underlying
ribs. I. The endoscopic equipment is used to make
any final refinements and to check hemostasis prior to
device placement. The device selection is made at
this time so that the dimensions of the pocket are
refined to match the dimensions of the device to be
placed.
■ The Agris-Dingman dissectors are then used to confirm the adequacy of the
peripheral extent of the dissection (TECH FIG 3H). They are used in a way
to minimize contact with rib periosteum. They are not used to manipulate the
muscle at this point in the procedure.
■ The endoscopic retractor and endoscope are reintroduced to recheck for
optimal hemostasis and complete any refinements of the soft tissue release in
preparation for device placement (TECH FIG 3I). On completion of this, the
endoscope is removed and retractor is used as a conduit for placement of

preferred irrigation solutions.
■ Device Placement
■ Selection of the specific device to be used can now proceed according to
surgeon preference. It is the author’s preference to make this decision at the
time of pocket refinement so that the dimensions of the tissue pocket can fit
the width of the device as closely as possible. It is also the author’s
preference that once the device is selected, the packaging is opened on the
back table and handled by the surgeon only with new gloves. Antibiotic
solution is placed into the implant container, after which the device is placed
into an insertion sleeve (TECH FIG 4A). Although the procedure can be
performed without this, it seems appropriate that this simple measure can
help decrease contact between the device and the skin and subcutaneous
tissues, including hair-bearing skin, to attempt to lessen exposure of the
device to bacteria during placement.
■ After placement, the correct position of the device vertically in the tissue
pocket is confirmed with the patient placed in a sitting position. Additionally,
the fit of the implant to the width of the pocket is checked, so that the
posterior aspect of the device lies flat against the rib cage and the anterior
surface is flat against the muscle and breast tissue in the dual plane. Any
adjustments are made as needed (TECH FIG 4B–F). If a shaped implant has
been used, the vertical position must be confirmed carefully, because these
devices are not able to be manipulated postoperatively in the same way that
smooth devices can be. Additionally, correct orientation of the device must
be checked by inspection of the upper device landmarks available, which
varies between manufacturers. A fiberoptic retractor is used for this
purpose.3,4

TECH FIG 4 • A. In preparation for device placement,
two 1-in. Deaver retractors are used to open access to
the tissue tunnel. One is placed parallel to the clavicle
and one parallel to the lateral rib cage to maximize the
opening. An insertion sleeve is used to assist in
placement and to minimize device contact with skin
and subcutaneous tissues. B–D. Photos are shown
following placement of the first device in the three
positions used to confirm that the device is placed to
the level of the modified IMF and to confirm the overall
adequacy of appearance. Note that the pocket fits the
implant precisely. E,F. Following placement of the
second device, the appearance of the second side is
confirmed and overall symmetry is checked.

■ Closure and Dressings
■ After completion of the second side, a fiberoptic retractor is used for
inspection of the upper tissue pocket. After meticulous hemostasis has been
obtained, the upper pocket is irrigate with saline solution. The deep dermis is
closed using 3-0 PDS, followed by 5-0 plain gut (TECH FIG 5A). The
axillary skin closure must be secure given its exposure to repetitive
movement and perspiration.
■ One inch Microfoam (3M Corporation) tape is used to reinforce the level
and shape of the IMF. This tape reinforcement also pushes tissue swelling
away from the IMF area.
■ Gauze is placed over the incision followed by 4-inch Microfoam tape. This
is important to generate pressure over the axilla to discourage fluid
collections and keep the devices as low as placed in the operating room
(TECH FIG 5B).
TECH FIG 5 • A. Incision is closed in a multilayer
fashion. B. Initial postoperative visit 1 day following
procedure. Tape along the IMF, placed at the
conclusion of the procedure is in place to help
stabilize the shape and level of the IMF.
PEARLS AND PITFALLS

Incision
design
■ Anterior extension of incision must be planned to not extend
beyond the posterior border of the pectoralis major muscle.
Incision to
pectoralis
major muscle
■ A thin skin flap is raised anteriorly from the incision until the
lateral border of the pectoralis major muscle is identified.
Entry into the
subpectoral
space
■ The lateral pectoralis major muscle fascia is incised allowing entry
into the space deep to the pectoralis major and above the pectoralis
minor muscle. A finger sweep is used to aid in identifying the
space clearly.
Optical cavity
creation
■ Cautery dissection is used to create a uniform space, or optical
cavity, first developing the areolar plane just deep to the pectoralis
major. This is continued until the entire undersurface of the
pectoralis major can be clearly delineated, in preparation for the
muscle release.
Pectoralis
major muscle
release
■ The initial cut into the pectoralis major muscle is made just above
the existing IMF, confirmed and controlled by correlating external
landmarks to internal anatomy.
■ This correlation must be rechecked repeatedly.
■ The IMF is then lowered by dissection just superficial to the
prepectoral fascia of the lower muscle cuff.
Postoperative
dressing
■ Pressure is placed to address the soft tissue tunnel used for device
placement, to prevent the device from moving upward in the early
postop period.
POSTOPERATIVE CARE
■ Postoperative pressure dressing is removed 1 to 3 days after the procedure.
The tape reinforcement of the IMF is kept in place for 1 week (FIG 5).
■ Patients are encouraged to begin controlled arm movement the day after the
procedure.
■ Patients are free to begin nonimpact aerobic exercise after 1 week. That
includes unlimited cycling. All aerobic exercise can resume after 2 weeks.

FIG 5 • Second postoperative visit at 1 week confirms
excellent shape. The tape along the IMF is removed but
additional support from a tight underwire bra is used to
help stabilize the IMF.
FIG 6 • A–C. Postoperative photos at 6 months.

OUTCOMES
■ Postoperative photos are shown on postoperative intervals. Photos are shown
of frontal, oblique, lateral, and axillary incision at 6 months (FIG 6) and 18
months (FIG 7).5
COMPLICATIONS
■ Complications associated with the procedure are those of breast augmentation.
■ Unique to this version of breast augmentation is the potential for the device to
shift back up into the soft tissue tunnel used for placement. Only after this
aspect of care has been mastered, in addition to technique for creation of the
tissue pocket, can shaped devices be used with this approach. If
textured/shaped implants shift upward during the recovery period, it is not
likely that they can be returned to the correct position.
FIG 7 • A–C. Postoperative photos at 18 months.

REFERENCES
1. Price CI, Eaves FF, Nahai F, Jones G, Bostwick J. Endoscopic transaxillary
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