Tumescent Anesthesia in Breast Augmentation and Reconstruction: Tips to Make Surgery Easier

Tumescent anesthesia is useful in liposuction and other plastic surgery procedures because of its great benefits for patients and surgeons ⁽¹⁾. The key to easy access in breast surgery is an accurate technique for dividing or separating anatomic spaces and to avoid pain. In this study, we describe tips to facilitate breast surgery with local tumescent anesthesia that will make the dissection of different spaces easier. As a complimentary issue, we proceed to blocking the last four intercostal nerves with lidocaine 1% with epinephrine. We use Klein solution and Klein needles or any other needle with blunt ending. Submammary incision is always performed.

1. Breast augmentation in subglandular space

Infiltration of local local anesthesia is applied to the incision. Then, a little stab is performed in the middle of it to allow Klein needle introduction. After this, tumescent infiltration between the gland and fascia occurs, as if opening a hand fan from medial to lateral.

2. Breast augmentation in submuscular space

A little stab is performed at the incision laterally near the anterior axillar line, through which the subglandular space is infiltrated. After skin incision, the m. pectoralis major is located, and the submuscular space is infiltrated under direct vision. Finding the space between both pectoralis muscles, major and minor, in the upper part of the pocket is as important as in the lower part of it to infiltrate the fascia below the inferior edge of m. pectoralis major for the creation of a submuscular/subfascial pocket without release of the muscle from sternal insertions, maintaining a unit muscle/fascia. This process will create a plinth to hold the implant ⁽²⁾. The subfascial plane acts as a shelf that gives firmness and stability to the new inframammary fold.

3. Capsular contracture in subglandular breast augmentation

Full capsulectomy is planned through an inframammary incision. Local anesthesia is performed up to the capsule, followed by capsulotomy and explantation. To allow the easy introduction of the Klein needle tip, one inch of the capsule is dissected, and then tumescent infiltration is performed, and the capsule is detached. If the patient has a previous periareolar incision, scar tissue dissection may be difficult at that point. The detaching procedure may be performed either with scissors or with blunt dissection.

4. Immediate breast reconstruction to place a tissue expander

This situation is the easiest one because real anatomy is widely exposed. The m. serratus anterior fascia is very thin and often not easy to dissect. Infiltration starts at an upper level between the m. pectoralis major and minor and then downward, overpassing the pectoralis major edge and creating a submuscular/subfacial pocket again.

These tips make surgery easier and give comfort to the patient, reducing post-operatory pain, in addition to conscious sedation or general anesthesia.

References

1) Kaplan, B. Breast augmentation by tumescent anesthesia is a safer, more affordable alternative to general anesthesia. Am J Cosmet Surg. (2004)21: 69-72 

2) Ventura, O., Marino, H., Marcello, G., Mitideri, V. Plinth to support mammary implants (in spanish) Cir.Plast.Iberlatinoamer.(2007) 33: 31-36