Expert guide: Aesthetic & Cosmetology 2015 24 June 2015 June 2015 25 Of course, meticulous surgical tech-nique with precise pocket dissec-tion is key. Obtaining hemostasis throughout the case, observing strict sterile technique, avoiding the use of gloves with powder, using antibiotic solution6, and employing technologies such as The Keller Fun-nel ™ which allow the implant to en-ter the breast without touching the surgeon’s gloves or the patient’s skin are all points to consider to minimise the risk of post-operative complica-tions.dimensions, and the size of the chest wall.1 Biodimensional planning with precise measurements will lead to greater success in breast augmenta-tion. Three dimensional computer imaging and simulation programs now allow surgeons to better visual-ise and precisely plan for breast aug-mentation surgery. Such programs also help to communicate possible results with given implants to a pa-tient. Chest wall asymmetries may be better detected and shown. Us-ing this technology may reduce the likelihood of operations for implant size change. It should be clear that the images simulated are not an im-plied guarantee of the result.2 Plastic surgeons have the option of using saline or silicone breast im-plants which are smooth or tex-tured, round or shaped, form-stable gel breast implants. Form-stable gel breast implants minimise the risk of wrinkling, rippling or capsular con-tracture while providing shape to the breast. Choice of incision is critical. The choices include inframammary fold, periareolar, transaxillary, and pe-riumbilical. The incidence of com-plications such as infection, altered sensation, and risks of capsular contracture are lowest with the in-framammary fold incision.3 This in-cision provides direct access to the subglandular and subpectoral planes without violating the breast paren-chyma. However, if the incision will not fall into the inframammary fold after augmentation or if the breast has a constricted lower pole, other options may be considered. The periareolar incision provides central access and enables one to lower the inframammary fold. The transaxil-lary incision allows one to avoid plac-ing a scar on the breast; however, it requires one to operate on tissue other than the breast and is associ-ated with a higher rate of complica-tions. The same is true of the tran-sumbilical approach. The key is to understand the benefits and disad-vantages of each of these incisions and choose the most appropriate in-cision for each patient.4 USA The plane into which the implant is placed is also critical. Placing the implant in the subglandular plane in the absence of adequate soft tis-sue coverage may result in thinning of the tissues, rippling, and palpa-ble implants. There is a higher inci-dence of capsular contracture with implants placed in the subglandular plane. Of note, textured implants in this plane may have a lower inci-dence of capsular contracture. All implants placed in this plane make mammograms more challenging to interpret compared to implants placed under the pectoralis major muscle. In practice, the majority of “subpectoral” implants are placed in the “dual plane” position whereby the upper pole of the implant is un-der the muscle and the lower pole of the implant is in the subglandular plane.5 Plastic surgeons have shown great success with the placement of implants in the dual plane to mini-mise the risks of developing com-plications associated with implants placed in the subglandular plane.