Incision decisions: What's the right breast augmentation approach? [Katerina Gallus, MD, San Diego]

Eva Sheie (00:04):
Welcome to the podcast, Where Before Meets After. Submit your questions for our experts at wherebeforemeetsafter.com. I'm your host, Eva Sheie.

Dr. Gallus (00:15):
I'm Kat Gallus. I'm a plastic surgeon in San Diego, California.

Eva Sheie (00:20):
When you are doing breast augmentation, where do you make the incisions?

Dr. Gallus (00:26):
So there's three locations that you can use to make an incision for an augmentation. The most popular one for me in my practice is an inframammary crease, so it's that little fold right underneath the breast, it's four centimeters. It's hidden, once you put the implant in, you won't see it because your breast will cover that, and I think it makes the most sense in terms of access to do that. The second most common option is peri areolar, so around the nipple areolar complex, it's a little half moon, basically at the bottom of the areola. That incision is sometimes popular. I try to avoid it unless I'm doing a breast lift at the same time, because you're going through the ductal tissue to do that. So there is a theory, unproven, but a theory that you're, it's a less sterile procedure, which as we know, if there's any contamination of that pocket at the time of augmentation, there is a risk for capsular contracture. Now we have ways around that. Now we use Keller funnels, but when I am doing an augmentation through an IMF incision, I will put little tegaderm stickers over the nipples as an added protection. And that's from a study that Bill Adams did. So that's one of the 14 point plans to sort of decrease the rate of capsular contracture.

Eva Sheie (01:44):
Like getting an oil change.

Dr. Gallus (01:46):
Yes.

Eva Sheie (01:48):
I think it's interesting that you jumped to preventing infection, because where my mind went was how do you fit an implant through that teeny tiny hole?

Dr. Gallus (01:57):
So I use a Keller funnel, which is, I say a very overpriced pastry bag. That's what it looks like, but it's brilliant. I have relatively small hands. I don't have very strong fingers. And so the traditional way of putting the implant in is to shove it through that small incision with your fingers, push, push, push. Again, you're exposing the implant to possible contamination. And so whoever invented, I think Thomas Keller, whoever invented the Keller Funnel, God bless him because you can do a no-touch technique where you take the implant from its sterile container, essentially pour it into the funnel, and then squeeze the end of the funnel into the pocket that you've created and implants in.

Eva Sheie (02:43):
It's ingenious.

Dr. Gallus (02:44):
It is ingenious. Simple but ingenious.

Eva Sheie (02:49):
That was two incisions.

Dr. Gallus (02:50):
That's right. I was just, so the third incision, which is one I don't do, but was trained on is the axillary incision. So that is an incision around the underarm area, and traditionally was used to place saline implants because you could get that through the small incision and slide it into the pocket. Also, traditionally, and again, the way I was trained was a blind dissection. So you can't see what you're dissecting, it's done with a certain surgical instrument that's pulling the muscle up for you. There are some techniques using the axillary incision that use a scope, basically you're using like an endoscope to see what you're doing. And so people who have trained in that technique use that, but it's a little bit difficult to really access the right pocket from that place. And if you ever need any correctional surgery, you're not going to be able to reuse that incision. So it's a one shot deal.

Eva Sheie (03:48):
And it's very unlikely that you won't need another surgery. Isn't that true too?

Dr. Gallus (03:52):
Yeah. So I tell all my women that are coming in for breast augmentation, that it's not a lifetime device, and it is, especially the younger, you are a hundred percent chance you're going to need another surgery down the road for lots of various reasons.

Eva Sheie (04:05):
Now, there's a really strange fourth incision that I want to ask you about, because when I started, actually, it was before I started learning everything there is to know about plastic surgery, my neighbor was a plastic surgery nurse, and her surgeon tried a lot of stuff on her. And at that, I'm talking about early two thousands.

Dr. Gallus (04:25):
Mm-hmm.

Eva Sheie (04:27):
This was a long time ago. She had a tuba, and so he put her in implants in through her belly button. And what do they do? Tunnel up through your abdomen, and then

Dr. Gallus (04:38):
It's a trans umbilical breast augmentation. I remember because around that time, DR 9 0 2 1 0, that show was popular, and he was going to ostensibly do a tube on the show, and he did it through an adominoplasty incision, which is not how you do it, but that's fine. And that's a whole other ball of wax. But yeah, that has been, there's a few holdouts who do the tuba, I think. Again, you're using a blind technique, you're going through the belly button, which is not your cleanest body part, and then dissecting up through the abdomen into the chest, and then there's no way you can possibly see what you're doing to set the pocket for the implant.

Eva Sheie (05:23):
And that's not very common anymore, that approach?

Dr. Gallus (05:26):
No, no.

Eva Sheie (05:26):
Where can we find you on Instagram?

Dr. Gallus (05:30):
I am at Restore SD, as in San Diego, plastic surgery.

Eva Sheie (05:34):
Sounds great. Thank you.

Dr. Gallus (05:35):
Thanks.

Eva Sheie (05:41):
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