A New Dissection Sequence, Based on Mapping Perforators of Pectoralis Major

Breast augmentation remains a leading cosmetic surgical procedure. Over the past two decades, various benefits and complications of pocket selection techniques have been described for breast augmentations. However, there has been limited evolution in the dissection technique sequence initially described by Tebbetts in his seminal publication.

We studied in detail the vascular anatomy of the pectoralis major and breast. We related the findings of anatomical dissections with the conclusions obtained by imaging and developed a systematic dissection sequence for creating a bloodless submuscular pocket.

Breast dissection was performed on ten fresh-frozen cadaveric tissues to observe vascular distribution mapping of the dual-plane pocket associated with the subpectoral space, and we replicated it in 727 female patients aged 18-66 years undergoing primary breast augmentation with a dual-plane pocket implant placement using a specific dissection sequence. Surgical data, implant information, patient demographics, and complications were systematically collected.

The mean patient age was 30 years. Round implants were used exclusively, with 80.05% textured and 19.95% smooth. Implant sizes ranged widely from 150 cc to 450 cc. We identified the presence of eight perforator vessels within the breast in the cadaver dissections and observed a large retropectoral avascular space. These findings are correlated with the images obtained with indocyanine green (ICG). Consequently, we described four retropectoral zones based on the mapping of the perforators. Importantly, this approach significantly reduced the incidence of possible postoperative hematomas, demonstrating its potential to improve surgical outcomes.

This practical dissection sequence of the four retropectoral zones aims to shorten our learning curve for precision, safe, and a bloodless retro-muscular pocket dissection.

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