42. Conization and mastopexy of breasts with silicone implants by means of two incisions of a few millimeters and the Elasticum thread and Jano Needle
KEYWORDS: mastopexy of breasts with silicone implants, breasts with implants, lifting of the breast with implant, aesthetic improvement of the breasts with silicone implant, Elasticum
The elastic thread mounted on the Jano needle (Elasticum, Korpo) can be used to improve the appearance of breasts that have silicone implants; the procedure is carried out through one or two incisions of a few millimeters. An elastic thread is implanted at a distance of about 6 cm from the nipple, at a depth ranging from 5 mm to 1 cm, according to the thickness of the patient's tissues. This thread, which encircles the nipple, conizes the breast and presses the implant into contact with the chest wall; this limits the movement of the implant, which is one of the causes of capsular contraction. Another elastic thread, which is implanted in a circle around the areola, conizes the apex of the breast and prevents the areola from dilating and the sub-areolar tissues from atrophying. Conization improves the appearance of breasts with silicone implants and counteracts drooping.
The conizing threads are implanted through a 1 cm peri-areolar incision. This simple mini-invasive Elastic Plastic Surgery procedure, which is performed under local anesthesia, makes breasts that have undergone additive mastoplasty look more natural.
The lower half of the outer circle is drawn at a distance of 6 cm from the nipple while the patient is standing. The upper half is drawn while the patient is supine.
In the case of drooping breasts, lifting is carried out in addition to conization. The operator raises the breast with one hand and marks the point where the skin of the chest begins; the elastic thread that will be used for mastopexy will be anchored to the subcutaneous tissue at this point.
This patient has drooping breasts, which present the typical appearance of a "ball in a sock". The previously performed round block has not corrected this drooping; it will now be corrected by means of the elastic thread.
The operator completes the design of the outer conizing circle. He draws the two tunnels through which the elastic threads will be implanted.
Local anesthesia is carried out along the pathway of the elastic threads. The anesthetic consists of 15 ml of 2% mepivacaine and ½ mg of epinephrine, which is added to 250 ml of Ringer solution or physiological solution.
The operation begins. The operator makes a 1 cm incision in the skin at the areolar margin where the tunnel is to begin. Scissors are used to dissect the tunnel at a depth of 1 cm. In this patient, the tissues covering the silicone implant are sufficiently thick. Dissection of the tunnel extends a few centimeters beyond the margin of the outer circle.
An Elasticum EP4 elastic thread is implanted. A spreader is inserted into the tunnel. The two-tipped Jano needle enters the tunnel and partially emerges on the outer circle. As always, a Klemmer is fixed to the end of the elastic thread. The elastic thread is pulled through.
The operator extracts the two-tipped needle until 1 cm of the posterior tip remains in the tissues, as indicated by the depth-marks on the shaft of the needle. The needle is then rotated and follows its pathway along the preoperative design. The Jano needle is partially extracted. The elastic thread is pulled through and placed under tension. When 1 cm of the tip remains in the tissues, the needle is rotated and continues along its pathway.
By means of slight up-and-down movements, the operator checks that there are no skin introflections and that the needle is following a uniform pathway through the subcutaneous tissue. During these maneuvers, the operator must take care to ensure that the Jano needle does not come out of the skin, because any attempt to reinsert it through the same hole will cause a skin introflection. If it does come out, the operator will have to extract the thread and repeat the implantation from the beginning.
Having almost completed the circle, the Jano needle is extracted until 1 cm of the tip remains in the tissues. It is then rotated and partially emerges at the level of the tunnel. The elastic thread is pulled through and placed under tension. When 1 cm of the tip remains in the tissues, the Jano needle is rotated and, with the aid of the spreader, emerges through the tunnel. The elastic threads are placed under tension and knotted under the guidance of the spreader. Conization presses the silicone implant into contact with the chest wall; this modifies the typical artificial, rounded form, making the breasts look more natural.
Conization of breasts that have undergone additive mastoplasty, especially of the areolar apex, may be required even only a few months after the original implantation procedure. If conization is performed a short time after the additive mastoplasty, enlargement of the areola and hypertrophy of the subareolar tissues will be avoided. If a thick prosthetic capsule has formed several times, we conize the breasts a few months after replacement of the prostheses, so as to limit the tendency of the implant to detach from the chest wall.
A thread is now implanted at the apex of the breast; this completes conization and gives the breast a more youthful appearance. The elastic thread is implanted at a depth of 1 cm. The distance from the areolar margin may vary from 1/2 cm to 2 cm.
The two ends of the elastic thread are placed under tension and knotted. Conization is now complete. As can clearly be seen, the conized breast is more prominent and has a broader base.
Conization is now carried out on the contralateral breast. The peri-areolar skin incision is made, the tunnel is dissected, the spreader is inserted and the elastic thread is implanted. Once the Jano needle has completed its circular pathway, it emerges from the tunnel and the two ends of the elastic thread are placed under tension and knotted under the guidance of the spreader.
The elastic thread used to conize the apex of the breast is now implanted. The Jano needle follows the preoperative design and emerges from the entry incision, where the two ends of the thread are knotted.
The small peri-areolar incisions are sutured.
Once the conization phase has been completed, the lifting phase begins; this will correct the drooping of the breasts. The patient is placed in a sitting position and the operator uses a dermographic pen to mark the most prominent point of the lower quadrant. From this point, he then draws an ellipse, which connects with the preoperatively drawn mark that indicates the point where the skin of the breast meets that of the chest. Lifting the breasts by means of threads has always been an impossible dream. Today, however, this dream has become a reality, thanks to the Elasticum thread and the Jano needle, which we have designed and patented. Owing to its elastic properties, this new surgical thread does not cut into the tissues. On account of their anatomical structure, the subcutaneous tissues of the breast and chest constitute a suitable suspensive structure.
In a few months, the elastic thread is transformed into a "natural ligament", which consolidates the suspension. Lifting the breasts by means of the elastic thread yields a permanent result.
Anesthesia is carried out along the pathway of the suspension thread. An incision of a few millimeters is made along the design of the ellipse, at the level of the anterior axillary line. A fine Klemmer is used to create a convenient deep space to house the knot.
The elastic thread is now implanted.
The thread is implanted at a depth of about 1 cm. The operator moves the two-tipped needle slightly up and down, to check that there are no skin introflections. In this case, the Jano needle has to be withdrawn and passed through the subcutaneous tissue at a greater depth. Each time that the two-tipped needle is rotated, the elastic thread is pulled through and placed under tension. The assistant checks that the elastic thread can run freely, without forming knots.
We have never implanted two elastic suspension threads in the same breast; however, we maintain that this can be done if the patient needs a greater lifting effect or if the breast is particularly heavy. Elastic lifting of the breasts through small incisions is carried out in cases in which drooping is not severe enough to require surgical mastopexy and skin removal. If a second thread is to be implanted, the upper portion of the ellipse will remain the same: the subcutaneous tissue of the chest skin situated at the point where it meets the skin of the breast. The lower portion of the ellipse is determined by placing the patient in the sitting position and marking the most prominent point of the lower quadrant with the dermographic pen.
In facial surgery, the elastic thread has revolutionized lifting by eliminating the need to dissect the cheeks and neck. In the body, it has revolutionized surgery of the buttocks, which are lifted by implanting two or three elastic threads. The technique presented in this video makes the results of additive mastoplasty look more natural and corrects the "ball in a sock" appearance of drooping breasts. The elastic threads are also used in surgical mastopexy; in this case, we do not touch the glandular stroma, but we de-epithelialize the skin and conize and stabilize the breasts by means of elastic threads. In this way, we avoid trophic damage to the breast tissue, which causes drooping to recur within a few years.
When the Jano needle reaches the small entry incision, the operator uses a Klemmer to facilitate its extraction. The two-tipped needle must emerge in the space created to house the knot, at the pre-established depth.
The two ends of the elastic thread are placed under tension. They are then knotted under the guidance of a Klemmer. When the elastic thread is knotted inside a small, deep cavity, the tip of a Klemmer is inserted into the cavity. The purpose of this maneuver is to enable the ends of the thread to be knotted more easily at the desired depth. If this maneuver is not carried out, the more superficial subcutaneous tissues may be pinched by the knot, causing a skin introflection. The elastic suspension thread is now implanted in the contralateral breast. The small skin incision is made on the anterior axillary line.
A Klemmer is used to create a convenient space to house the knot. The elastic thread is implanted at a depth of 1 cm. The Jano needle follows the design.
When the two-tipped needle reaches the end of its pathway, the operator extracts it from the small incision with the aid of the Klemmer. The two ends of the thread are placed under tension. The tip of the Klemmer is inserted into the small cavity in order to facilitate knotting.
The small incision is sutured. The operation is over.
For several months, the patient will wear a bra that lifts the breasts, to avoid exerting traction on the suspension threads. In the first week, the bra will also be worn at night.
Breasts that have silicone implants are given a conical shape and are lifted by elastic mastopexy. They have a natural, pleasing appearance, and no longer look artificial. The result achieved by implanting the elastic threads is permanent.
Capurro S. (2019): Conization and mastopexy of breasts with silicone implants by means of two incisions of a few millimeters and the Elasticum thread and Jano Needle. CRPUB Medical Video Journal. Elastic Plastic Surgery section, www.crpub.org.
Are there any risks in using the Jano needle in breasts with silicone implants?
We normally implant the conizing elastic threads at a depth of ½ cm and the peri-areolar thread at a depth of 1 cm. In this patient, we performed conization at a depth of 1 cm.
We have never had any problems regarding the silicone implant or vascular issues.
Do you also operate on non-drooping breasts that have undergone additive mastoplasty?
Yes, we often perform conization in order to eliminate the artificial appearance created by the implant. In this way, the breasts become pointed and the anterior portion is more mobile and natural. After conisation, the areola does not widen and the subareolar tissues do not atrophy.
Is the elastic suspension thread fixed to the subcutaneous tissue of the chest?
Yes. The Elasticum EP4 (Korpo, Italy) elastic thread is fixed to the subcutaneous tissue of the chest exactly at the point where the chest skin meets the breast skin. The structure of the subcutaneous tissues of the chest is suitable for suspension, as indeed are the subcutaneous tissues of the breast.
Is the operation painful?
Our patients have never complained of feeling pain. Moreover, if the patient wears a supporting bra, the suspension thread is not under tension and causes no discomfort.
Can this innovative Elastic Plastic Surgery procedure also prevent drooping of the breasts?
Yes. The new conizing and suspensive "ligaments" prevent stretching of the skin and drooping.
What are the results like?
The results of conization are excellent. The breasts look natural and do not seem to have been operated on. The results of lifting are also very good. If the breasts present severe drooping, we have to assess whether the additive mastoplasty was performed properly, and whether the implants were chosen and positioned in accordance with the classic canons of beauty. However, after implantation of the elastic threads, it is still possible to correct the result of an imperfect mastoplasty procedure, if necessary, by moving the areola, so as to obtain a more pleasing result.
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