Placing the incision in the inframammary fold (IMF) affords perhaps the best compromise between providing direct access to the breast at the expense of creating a scar. The IMF incision offers straightforward exposure for pocket dissection with the aid of a simple lighted retractor. Submuscular, subpectoral, subfascial and subglandular pockets can all be created with ease and the limits of the dissection can be determined under direct vision. Complete hemostasis can also be assured as individual vessels can be controlled and pocket manipulation with precise soft tissue release is also easily facilitated. The position of the inframammary fold can be maintained or lowered with accuracy due to the direct access afforded by the proximity of the incision. Implant insertion and positioning are also easily accomplished, a fact that is particularly advantageous when using shaped implants that must be oriented correctly. The disadvantage relates to the creation of a telltale cutaneous scar in the vicinity of the breast. For this reason, it is best to place the scar directly in the IMF as it tends to be quite inconspicuous in this location, particularly when the breast is of sufficient size to fall over the fold (Figure 4.4). In these situations, the scar will only be visible when the patient lies flat or raises her arms up over her head.

Figure 4.4 Appearance of the scar in the inframammary fold 1 year after breast augmentation.

Although in terms of popularity, the periareolar incision is second to the inframammary fold incision, it remains as an attractive option for many plastic surgeons for two reasons. First, the resulting scar generally heals in a fine line fashion and is essentially imperceptible in many patients (Figure 4.5). The fact that the scar is situated at the junction of the pigmented areolar skin with the lighter lower pole breast skin assists greatly in visually masking the scar. Second, the only time the scar is potentially visible is when the breast is bare which, for many women, occurs only in controlled private settings. One unique situation where the periareolar incision has particular advantage is in the patient who presents with very small breasts with little to no inframammary fold. Here, the breast often cannot be augmented enough to cause the breast to fold over an inframammary fold incision with the result being an immediately obvious and visible inframammary fold scar. In these cases, rather than risk scar visibility, a better option is the periareolar incision location, where the scar is better camouflaged. Other advantages of the periareolar incision location include the fact that, as with the IMF incision, direct access is afforded to the breast, which allows accurate pocket dissection and direct hemostasis. The incision is generally made along the inferior hemisphere of the areola, at the junction with the lighter lower pole breast skin. From here, two approaches can be used to access the underside of the breast and create the pocket:

Figure 4.5 Appearance of the scar along the inferior border of the areola 1 year after breast augmentation.

Figure 4.6 Through a periareolar incision, access to the underside of the breast can be achieved by using a direct transparenchymal dissection that extends directly toward the chest wall. This approach provides direct exposure to the underside of the breast at the expense of potentially seeding the implant pocket with bacteria present within the breast ducts.

Table 4.1 The circumference of a circle can be calculated using the formula π× diameter. By using this formula and dividing the circumference by two, the static length of a periareolar incision can be calculated for areolas of several different commonly encountered dimensions

Figure 4.7 To avoid exposing the implant to bacteria contained in the breast ducts, an alternative approach to the underside of the breast through the periareolar incision can be created by dissecting along the breast fascia inferiorly down to the inframammary fold. Once at the fold, dissection then proceeds superiorly to create the desired pocket.

Figure 4.8 By releasing the lower pole of the breast away from the lower pole breast skin, the intact breast parenchyma can be lifted away from the fold to allow the placement of a breast implant. By combining the release of the breast parenchyma with the mass effect provided by the implant, an aesthetic expansion and filling out of the lower pole of the breast can be achieved.

The transaxillary incision provides an access site to the breast which heals with a well-hidden and, in most instances, imperceptible scar that is not located on or near the breast (Figure 4.9). As such, it is not generally recognized as a telltale sign of previous breast surgery. This significant advantage must be weighed against the potential for compromised accuracy in pocket dissection due to the remote location of the incision as well as the occasional patient who forms a bad scar in this otherwise visible location. There are two techniques to utilize this incision as it relates to pocket development. In both methods, the incision is located high in the axilla and is oriented horizontally at a point just lateral to the lateral margin of the pectoralis major muscle. The skin is incised and spreading dissection is used to identify the lateral border of the pectoralis major. At this point the underside of the pectoralis can be separated bluntly using a sound-type elevator to develop this plane, which opens up very easily. Crossing vessels from the chest wall to the muscle are simply avulsed and go into spasm, which usually checks the bleeding. Any tethering of the fibers of origin of the pectoralis major that adversely affect the shape of the breast are released by likewise avulsing these fibers loose until the pocket of the desired shape and dimension is developed. The implant is inserted and the incision closed. Clearly, the major difficulties associated with this approach involve the blunt and relatively blind nature of pocket development and the potential for uncontrolled bleeding due to the lack of direct control of bleeding points. Even with these potential difficulties, it must be pointed out that many surgeons can and do use this approach with success. However, in an attempt to increase the control afforded by this approach, some surgeons have incorporated endoscopic technique into the procedure. Once the plane on the underside of the pectoralis major is developed, an endoscope is inserted and, with the aid of standard endoscopic instruments, bleeding points are controlled and the fibers of origin of the pectoralis major muscle are released as needed under direct endoscopic vision to accurately create the desired pocket and position the inframammary fold with precision. Combining the use of the endoscope with the well-concealed transaxillary incision is an excellent way to combine the advantages of direct pocket development with a remote and imperceptible scar. The disadvantages are related to the requirement for extra instrumentation, the additional technical expertise required to utilize the endoscope and the potential for bleeding that may be difficult to control even with the aid of the endoscope, particularly if the second intercostal perforator in the upper inner portion of the pocket is inadvertently divided. Additionally, plane selection is limited as, although it may be technically feasible to utilize the subglandular plane with this approach, it is difficult and, practically speaking, most surgeons use the subpec­toral plane with this technique. It must also be pointed out to the patient ahead of time that, should future problems develop such as capsular contracture or implant malposition, many patients are going to receive an additional scar on the breast in the course of correcting the problem. Finally, this technique allows saline implants to be placed without difficulty; however, larger gel devices, textured devices and anatomically shaped cohesive gel devices all may prove to be variably difficult to insert without damaging the implant. These potential disadvantages do not diminish the utility of the transaxillary approach and many surgeons do use it successfully. However, all of these factors must be taken into account when contemplating the use of the transaxillary incision location.

Figure 4.9 Appearance of the scar in the axilla 1 year after transaxillary breast augmentation.

In a further effort to erase any stigmata of a procedure on the breast, the transumbilical breast augmentation (TUBA) procedure has been developed. In this approach, an incision is made in the umbilicus and a hollow trocar is bluntly inserted through the subcutaneous tissue, angling upwards toward each breast. The pocket, either subpectoral or, more recently, subglandular, is bluntly opened enough to allow the passage of an uninflated temporary ‘expander’. This device is attached to a long fill tube which exits through the umbilicus. By over inflating the ‘expander’ with air, the pocket is developed bluntly as the muscle and/or breast is avulsed away from the more rigid chest wall. The more dense attachments of the inframammary fold prevent to some degree inadvertent lowering of the fold, and the pocket opens more or less under the breast. The ‘expander’ is deflated and removed and the final saline implant shell is passed through the trocar uninflated and attached to a second long fill tube. The implant is filled with saline to the desired fill volume and the fill tube and trocar are removed to complete the procedure. TUBA remains a controversial procedure. It must be stated that the scar generally is well hidden and some surgeons are able to obtain consistent aesthetic results using the technique. However, the disadvantages and potential complications are significant and must be taken into serious consideration when contemplating the approach. Due to the limited access tunnel, it is possible to use only saline implants, which limits implant selection. Also, because pocket dissection is performed bluntly from a remote location, control over the size, location and symmetry of the dissection space is compromised compared to the direct control afforded by incisions located closer to the breast. If bleeding occurs, it cannot be stopped other than with direct pressure, which increases the potential risk for hematoma development. One potential comp­lication unique to the TUBA procedure involves the creation of permanent soft tissue distortion with visible grooving in the upper abdomen extending up from the umbilicus to the breast that can develop in trim patients as a result of the trocar passing through the thin subcutaneous layer. Finally, any revisionary procedure that cannot be performed through the periumbilical access site will require an additional separate incision on the breast. For these reasons, TUBA is viewed less than favorably by many surgeons and the lack of direct control of many of the factors involved in offering consistent results in breast augmentation is deemed enough of a disadvantage to make the remote and inconspicuous umbilical scar an unreasonable tradeoff.

Early on in the development of breast augmentation as a viable aesthetic procedure, it made intuitive sense to place the implant directly under the breast on top of the underlying musculature. It soon became clear, however, that, with this technique, capsular contracture was an alarmingly common complication and one possible etiology was thought to be bacterial contamination of the implant space from the ducts in the overlying breast. Therefore, in an attempt to isolate completely the breast implant from the overlying breast parenchyma and thus minimize any bacterial contamination, the submuscular pocket was developed. In this procedure, a pocket is created under the pectoralis major muscle by lifting the lateral margin of the muscle away from the chest wall and undermining the muscle over to the medial fibers of origin just lateral to the sternum. Typically, every attempt is made to keep the fibers of origin along the inframammary fold intact to prevent the implant from slipping out from under the muscle inferiorly thus preserving the completely submuscular location of the pocket. Laterally, the muscle fibers or simply the superficial fascia of the serratus anterior muscle are elevated away from the chest wall and the implant is slipped under this muscle/fascial layer. By approximating the lateral margin of the pectoralis major to the serratus muscle/fascia, the implant is completely isolated from the overlying breast parenchyma (Figure 4.10). Theoretically, providing a barrier to potential bacterial seeding of the implant space from the breast ducts will prevent or at least moderate the subsequent development of capsular contracture. Also, keeping the inferior muscle fiber attachments intact is thought to provide strong support to the inferior pole of the breast, which can prevent postoperative inferior migration or ‘bottoming out’ of the breast implant. Also, by covering the implant with a layer of muscle, the contours of the superior and superomedial borders of the breast along the edge of the implant are softened, creating a more natural breast shape. While these factors may be an advantage, there are significant drawbacks to this technique. Perhaps the greatest problem associated with the use of the completely submuscular pocket is the potential for superior implant malposition. This is because anatomically, in many patients, the position of the inferiormost fibers of origin of the pectoralis major muscle can be located slightly above the location of the attachments of the inframammary fold (Figure 4.11). When this relationship is present, placing an implant in a completely submuscular pocket or, for that matter, even in a subpectoral pocket, without release of the inferior fibers of origin of the pectoralis major muscle will not allow the breast implant to sit low enough and it will be appear to be superiorly malpositioned in relation to the position of the breast mound on the chest wall. The resulting breast contour will then very likely demonstrate a superior pole bulge with the breast appearing to fall away from the inferior pole of the implant. When severe, this appearance has been referred to by some as a ‘snoopy dog’ type deformity (Figure 4.12). The identification of a mismatch in breast position versus implant position can be difficult to appreciate intraoperatively as the implant malposition may not become apparent until the patient is placed upright. Lying supine, the breast mound tends to shift superiorly and an implant in a submuscular pocket may appear to be well matched to the breast positionally. It is only later when the patient is seen upright in the office that the malpositioned breast implant becomes apparent. It is likely that this phenomenon is at least partially responsible for the widely held opinion that submuscular implants tend to ‘ride high’. It may be that the so-called high-riding implant more accurately represents an implant that was unwittingly malpositioned superiorly at the time of surgery. This observation is but one of many that underscores the importance of sitting any breast patient up 80 to 90 degrees during the procedure so these types of relationships can be accurately assessed intraoperatively and appropriate changes made in implant position as needed. Another limitation associated with the use of a submuscular pocket relates to the volume of the space that can be opened up under the muscles. The pectoralis major and serratus anterior muscles are normally closely applied to the chest wall in their resting state and the degree to which they can be elevated away from the chest wall and still keep the peripheral attachments intact is limited. For this reason, larger implants may not comfortably fit within the confines of the dissected pocket. Also, should the pocket be constricted at all, due either to an inelastic muscle cover or to the use of a large volume device, there is a tendency for the implant to become compressed, particularly in the lower pole, resulting in lower pole flattening and excess upper pole fullness. It is for these reasons that the total submuscular pocket is used only sparingly in breast augmentation.

Figure 4.10 When the implant is placed in a completely submuscular pocket, it is covered by the pectoralis major muscle centrally, superiorly and medially and the serratus anterior muscle and fascia laterally. In this fashion, the implant is completely isolated from the overlying breast parenchyma.

Figure 4.11 In some patients, the location of the inferiormost fibers of origin of the pectoralis major muscle can be located several centimeters above the native inframammary fold. When this relationship is present, placing an implant under the pectoralis major muscle without releasing the inferior fibers of origin will result in an implant position that is too high in relation to the rest of the breast mound. This superior implant malposition results in a distorted shape after breast augmentation.

Figure 4.12 Lateral view of a patient after undergoing subpectoral breast augmentation without release of the inferior fibers of the pectoralis major. The implant is superiorly malpositioned, creating a prominent superior pole bulge. Also, the main substance of the breast can be seen extending away from the inferior edge of the implant, creating a very unaesthetic breast contour that has been referred to as a ‘snoopy dog’ type of deformity.

In an attempt to address the apparent difficulties associated with the completely submuscular pocket, the partial subpectoral pocket was developed. In this procedure, the pectoralis major is released along the lateral border of the muscle and the subpectoral space is developed as before. Here, however, no portion of the serratus anterior is elevated at all and the inferomedial fibers of attachment of the pectoralis major muscle are released, allowing the muscle to retract up and away from the inframammary fold. The net effect of this release is twofold. First, the tension on the pocket is reduced significantly as a result of releasing the muscle fiber attachments. When the total submuscular pocket is used, the broad, flat pectoralis major can function as a tethering layer, preventing the pocket from expanding fully to accommodate the implant. By releasing the inferior attachments of this tethering layer, the muscle is released and the skin envelope of the lower pole of the breast is recruited to assist in defining the dimensions of the pocket. The result is a bigger pocket with less compressive force on the implant and a more compliant soft tissue/implant interface, allowing the creation of a softer breast. Second, as a result of releasing the muscle along the inframammary fold, the implant can now be positioned low enough to place the inframammary fold in an anatomically correct position. As a result, the upper portion of the implant remains covered by the pectoralis major muscle but the lower portion of the device is in contact with the underside of the breast (Figures 4.13, 4.14). The portion of the implant that is covered by muscle will change from patient to patient as breast position on the chest wall and the exact point of origin of the pectoralis major is subject to anatomic variation. However, the ultimate effect of this pocket plane is to once again soften the upper medial pole of the breast due to the padding created by the muscle and yet allow the breast implant to be positioned low enough on the chest wall to anatomically fill out the breast contour. The pocket is also very easily developed either under direct vision or bluntly through any incision location. The subpectoral pocket is also the preferred pocket location for women undergoing mammographic screening of the breast as the breast implant is relatively easily pushed up and out of the way, a maneuver that affords better breast compression and a more complete mammogram.

Figure 4.13 (A) When the inferior fibers of origin of the pectoralis major muscle are left intact, the implant can be prevented from descending all the way to the native inframammary fold, resulting in superior implant malposition. (B) When the lower fibers of origin are released, the implant is allowed to settle to the bottom of the pocket, creating a more complementary relationship between the implant and the breast, resulting in an improved breast contour.

Figure 4.14 (A) Lateral schematic diagram demonstrating that when the lower fibers of origin of the pectoralis major muscle are not divided, the implant can become compressed by the muscular layer, resulting in lower pole flattening, superior pole bulging and a positional implant/breast mismatch. (B) With release of the muscle along the inframammary fold, the dimensions of the pocket are increased, the tension on the implant is reduced and the implant is allowed to settle to the bottom of the pocket, creating a more natural and aesthetic breast shape.

While the use of a partial subpectoral pocket successfully addresses several of the problems noted with a total submuscular pocket, there are some disadvantages associated with the technique. Technical skill must be exercised in the undermining and releasing of the muscle to create a breast shape that will be symmetric from side to side. While this may seem to be a straightforward endeavor, it can actually require a fair bit of care to accomplish symmetric release of the muscle inferiorly as factors such as pre-existing asymmetry in the fibers of origin as well as a basic asymmetry in breast size and shape itself can come into play. Failure to release the muscle symmetrically can lead to postoperative implant malposition. Also, due to the fact that the integrity of the total muscle cover is interrupted, a portion of the implant becomes exposed to the overlying breast parenchyma. Theoretically, bacterial seeding of the implant space could occur, possibly leading to capsular contracture. Despite this concern, numerous studies have concluded that the subpectoral plane is associated with a reduced capsular contracture rate as compared to the subglandular plane. This apparent inconsistency between theory and observation underscores the fact that capsular contracture is a multifactorial process that remains incompletely understood even today. Therefore, despite the technical challenges that use of the partial subpectoral pocket presents, the advantages associated with use of this technique are significant and it remains as the standard approach for the vast majority of plastic surgeons who perform breast augmentation.

When either the total submuscular or partial subpectoral pocket plane is used, it must be recognized that the overlying musculature retains its contractile ability. As a result, when a breast implant is placed under the pectoralis major muscle, the implant will be compressed when the muscle contracts. Typically, this movement tends to draw the implant in an up and out direction and this directed compression creates a contour deformity in the breast that can easily be seen when the patient places her hands on the hips and pushes inward. Occasionally, the deformity is so prominent that the distortion in breast shape can be seen through tight-fitting clothes. The magnitude of the deformity caused by this breast animation is highly variable and, fortunately, it is usually only minimal to moderate in severity (Figures 4.15, 4.16). However, at times, the degree of the distortion created by contraction of the pectoralis major muscle can be dramatic (Figure 4.17) and, in revisionary patients, undesired breast animation is often one of many issues that can lead patients to seek re-operation (Figure 4.18). In an attempt to head off any potential postoperative dissatisfaction and ensure a fully informed patient, it is very reasonable to discuss breast animation as a potential complication during the preoperative evaluation and education of the patient. Short video clips (DVD clips 2.01, 2.02, 2.03, 2.04) are very instructive and can ensure that the patient understands completely the rationale for using the partial subpectoral pocket and what effect that decision may well have on her postoperative result.

Figure 4.15 (A) Five-year postoperative appearance of a patient after partial subpectoral breast augmentation using a smooth-walled saline implant. With the arms resting comfortably at the side and with no contraction of the pectoralis major muscle, the breasts have a pleasing aesthetic contour. (B) As the patient places her hands on her hips and pushes inward, the pectoralis major muscle contracts, drawing the underlying implant laterally and slightly upward. The intermammary distance increases as the implants are pulled laterally and the lower pole of the breast flattens along with the medial portion of the inframammary fold. This case is fairly typical of the degree of breast animation that occurs after partial subpectoral breast augmentation.

Figure 4.16 (A) Four-year postoperative appearance of a patient after partial subpectoral breast augmentation using an anatomically shaped cohesive gel implant. Again, with the arms resting at the side, a pleasing and natural breast contour is demonstrated. (B) With the hands pushing on the hips, the pectoralis major muscle contracts, creating the same pattern of breast animation seen with the saline implant. This case is representative of the fact that, while it may make intuitive sense that firmer cohesive gel devices might protect against breast animation, in fact these devices are subject to the same forces as any other implant and react in exactly the same fashion.

Figure 4.17 (A) Two-year postoperative appearance after partial subpectoral breast augmentation with a smooth round saline implant. At rest, a pleasing result is demonstrated. (B) With contraction of the pectoralis major muscles, significant displacement of the implant into the upper pole of the breast with associated distortion and flattening of the implant is noted. This degree of breast animation can understandably be a major source of patient dissatisfaction.

Figure 4.18 (A) Preoperative appearance of a patient who has previously undergone periareolar mastopexy. Her static postoperative result reveals a significant breast asymmetry, widening of the right areola and left-sided capsular contracture. (B) As the patient contracts her pectoralis major muscle, a significant deformity develops in each breast. Again, both breasts are drawn laterally and superiorly and the intermammary distance widens markedly. On the left, the released inferior edge of the pectoralis major remains attached to the overlying tissue such that, as it is drawn superolaterally, a prominent cleft is created in the inferomedial breast contour. This cleft is not present on the right, possibly indicating that the muscle was asymmetrically released at the original procedure. This degree of deformity is much less common and would be described as marked.

The second most commonly utilized pocket for breast implant placement is the subglandular pocket. In this procedure, the subglandular space above the pectoralis major muscle is opened leaving the pectoralis muscle fascia attached to the muscle (Figure 4.19). The space dissects open readily and the limits of pocket development can be precisely controlled, which eases the technical challenge of dissecting pockets of the same dimension and location for each breast. Crossing vessels and nerves can be identified and preserved medially and laterally as desired and the pocket can be easily accessed through either a periareolar or an inframammary fold incision. Any type of implant can be used with a subglandular pocket and shaping maneuvers such as scoring of the underside of the breast to release tethering constrictions are greatly facilitated due to the direct exposure of the gland. As a result of placing the implant above the muscle, postoperative animation of the breast is markedly diminished and, at most, only a slight shape change may occasionally be noted with contraction of the pectoralis major muscle due to tethering of the capsule to the muscle. Typically, the recovery after undergoing a subglandular breast augmentation is more straightforward with many patients reporting a less painful experience overall. Despite these advantages, the subglandular pocket is used with care as the disadvantages can be significant. Perhaps, most importantly, it is generally agreed that the incidence of capsular contracture is greater in subglandular breast augmentation. What remains unknown is what effect that newer breast implant designs will have on this complication. More recent silicone gel breast implants have been designed to have an outer shell that is much more resistant to gel bleed than earlier implants and recent studies have reported rates of capsular contracture that are not much different from those associated with subpectoral placement. Perhaps just as important is the effect of the subglandular pocket on breast shape. Because the upper inner portion of the pocket is not padded by the pectoralis major muscle, implant edge visibility and palpability in this area can become an issue in thinner patients who do not have enough native breast parenchyma to mask the shape of the underlying device. This implant visibility becomes more apparent as the patient flexes the pectoralis major muscles and a sharper medial and superior implant margin can become evident (Figure 4.20). For these reasons, many surgeons limit the use of the subglandular pocket to those patients who have an upper chest soft tissue thickness of 2 cm or more, or in patients who will require soft tissue scoring on the underside of the breast as in patients who present with a tubular breast deformity. Also, in mastopexy patients, the soft tissue lifting effect of placing an implant under the breast is enhanced if the pectoralis major muscle is not positioned as a potentially tethering layer inhibiting implant projection. As a result, many surgeons will choose the subglandular plane for those patients undergoing augmentation mastopexy.

Figure 4.19 (A) Schematic lateral cutaway diagram of the breast prior to subglandular breast augmentation showing the pectoralis major muscle, parenchyma and fascia. (B) Same view after subglandular breast augmentation. The implant is positioned on top of the pectoralis major muscle and fascia and lies underneath the breast parenchyma, as well as the skin and fat of the chest wall.

Figure 4.20 (A) Postoperative appearance of a patient after subglandular breast augmentation. At rest, the contours of the breast are soft with no prominent edges or step offs being noted at the periphery of the implant. (B) As the pectoralis major muscle contracts, the effect of the muscle pulling on the overlying soft tissue framework tightens the skin envelope, creating sharper contours around the periphery of the implant. Therefore, although there is no animation deformity as is noted after subpectoral breast augmentation, thinner patients can exhibit increased implant visibility when the implant is placed in the subglandular plane.

Closely related to the subglandular space is the subfascial pocket. This technique was designed in an attempt to minimize the potential disadvantages traditionally associated with the partial subpectoral pocket related to postoperative breast animation and yet preserve the improved upper and medial pole contour that the partial subpectoral pocket can provide. In this technique, the lower border of the breast is elevated along with the investing fascia of the pectoralis major muscle. Initially, this plane can be somewhat difficult to develop as the attachments of the breast septum must be dissected free as they course transversally across the mid-aspect of the pectoralis major muscle. Associated with this fascial attachment will be several prominent perforators that are easily controlled. Above this point, however, the fascia comes up easily and any small bleeding points that are encountered are easily controlled. Dissection then continues superiorly under the breast until the superior extent of pocket dissection is complete (Figure 4.21). Although quite thin, theoretically this fascia is thought to provide a tethering force around the perimeter of the breast implant that then softens the contours of the peripheral edges of the breast, leading to less implant visibility. It is postulated that this effect is similar to the softening of the superomedial implant edges that occurs with partial subpectoral placement, but without the attendant subpectoral distortion that variably occurs when an implant is placed under the pectoralis major muscle. In practice, this plane is rather easy to develop; however, the fascial layer is quite thin and any resulting improvement in breast shape that occurs is modest at best with other factors including body habitus, implant style and size and implant fill exerting a much more profound impact on breast shape. For this reason, use of the subfascial pocket has yet to attain wide popularity. One unexpected advantage that can seen when using this plane relates to the accuracy of pocket dissection. By elevating the fascia with the breast in the medial portion of the pocket, it is technically easier to identify and preserve the medial internal mammary perforators and avoid inadvertent injury to this vigorous source of blood supply to the breast. Another more theoretical advantage relates to a potential shaping advantage afforded by differentially scoring the fascia in the lower half of the breast. The resulting release of tension in the lower half of the pocket coupled with a mild fascial-induced tethering in the upper half can create differential tension on the pocket that tends to restrict upper pole fullness and maximize lower pole projection. However, whether or not such differential pocket dissection can aid in ‘shaping’ the subsequent breast implant, creating an improved breast shape over the long term, remains to be demonstrated.

Figure 4.21 (A) Lateral schematic diagram demonstrating the relationship of the pectoralis major muscle and fascia to the overlying breast. (B) After creation of a subfascial pocket, the pectoralis major fascia remains attached to the underside of the breast and the implant is positioned between the muscle and the fascia.