Summary/Key Points

According to the most accurate statistic databases all around the world, the number of breast augmentation procedures has been increasing over the years.^1,2 The surgical approach, implant selection, and especially implant plane or pocket plane have been subjects of controversy. This chapter will discuss different approaches used to insert a breast implant subfascially, including anatomical considerations, patient selection and indications, operative techniques, advantages, pitfalls and postoperative care.

Anatomical Considerations

The breast is essentially a skin appendage contained within layers of the superficial fascia. The superficial layer of this fascia is near the dermis and is not distinct from it. The deep layer of the superficial fascia is more distinct and is identifiable when the breast is elevated in a subglandular augmentation mammaplasty.³ There is a loose areolar tissue between the deep layer of the superficial fascia and the fascia that covers the pectoralis major and continues to cover the adjacent rectus abdominis.⁴

The pectoral fascia is a dense connective tissue that originates from the clavicle and sternum and covers the pectoralis major muscle and continues to cover the adjacent rectus abdominis, serratus anterior, external oblique muscle and extends toward the lateral border of the pectoralis major muscle to form the axillary fascia, as we can see in Figure 25.1. At the caudal border of the pectoralis muscle, the clavipectoral, pectoral, and serratus anterior fasciae become continuous and form the suspensory ligaments that extend to the breast inframammary fold.⁵

Fig. 25.1 A Pectoralis fascia – cadaver dissection. B A mammogram showing the pectoralis fascia around the silicone implant.

The pectoral fascia can be bluntly dissected along the subfascial plane and it has some specific characteristics. At the level of the second rib, the pectoral fascia tightly connects with the superficial fascia of the breast and it is difficult to dissect bluntly. Along the point that corresponds to the fourth intercostal space, the horizontal septum originating from the pectoral fascia connects with the nipple. At the inframammary crease, a dense connective tissue is found connecting the skin crease and the pectoral fascia. Fascial thickness has been found to vary from 0.2 to 1.14 mm along its different portions. Perforating vessels and nerves emerge mainly from the medial, lateral and lower part of the fascia.⁶

Patient Selection and Indications

The pectoral fascia helps to support the implant and even in slim patients it gives a smoother transition in the upper pole of the breast, improving the final aesthetic result (Fig. 25.2).^5,7,8 The exception would include thin patients who desire relatively large implants. In these patients it is better to use a round implant in the retromuscular pocket, or an anatomical/shaped implant subfascially (Fig. 25.3). Some other possible advantages clinically noticed with subfascial breast augmentation still need to be investigated. We have had the impression of reducing postoperative breast ptosis due to fascial support, and minimizing incidence of capsular contracture, possibly due to contact of the muscle fibers with the implant.

Fig. 25.2 A, C Preoperative and B, D postoperative views of a patient who underwent transaxillary, subfascial breast augmentation (round, textured, 275 cc, high profile, silicone gel implant).

Fig. 25.3 A, C Preoperative and B, D postoperative views of a patient who underwent transaxillary, subfascial breast augmentation (anatomic shape, textured, CPG 323, 260 cc, high profile, medium height, silicone gel implant).

Transaxillary subfascial breast augmentation can be indicated for every patient who does not need mastopexy. Augmenting the breasts without leaving a scar on them is the major advantage in this technique and has been frequently desired by young patients (Fig. 25.4). The fact of creating a scar in a low tension area, far from the breasts, makes this approach the preferred technique in patients with known history or risk factors for hypertrophic scars and keloid. Preoperative conversation regarding axillary lymphatic drainage of the breasts and sentinel node implications is advisable. Recent studies published by our group showed that the sentinel node in the axilla can be preserved after transaxillary breast augmentation if some technical details during dissection are respected.^9,10 This technique requires special instruments (long lighted retractors or video-endoscopic apparatus) and has a longer learning curve. Any kind of implant can be used through this access, however special attention should be given to avoid misplacement of anatomical implants.

Fig. 25.4 A, C Preoperative and B, D postoperative views of a patient who underwent transaxillary, subfascial breast augmentation (round, textured, 280 cc, high profile, silicone gel implant).

The periareolar approach can be indicated for patients with medium or large size areolae, since the lower half perimeter of the areola must allow an incision of at least 4 cm. A well defined transition between areola and breast skin is also important to have a less visible scar. Patients who have breasts with mild ptosis that will probably not be corrected by the breast implant chosen are good candidates for a periareolar mastopexy (Fig. 25.5). Patients with tuberous breasts usually present with lower pole hypoplasia and some degree of nipple–areola complex weakness and prolapse. In these cases we have also used the circumareolar approach with nylon round-block suture to improve nipple–areola complex herniation. The subfascial pocket is created, but the fascia is radially incised in the lower breast in order to allow more skin distention. Round implants can be used for mild tuberous breasts, however in more severe cases anatomical shaped implants are better indicated to obtain greater lower pole projection.

Fig. 25.5 A, C Preoperative and B, D postoperative views of a patient who underwent periareolar subfascial breast augmentation and mastopexy (round, textured, 270 cc, ultra-high profile, silicone gel implant).

The inframammary breast augmentation is the simplest and most direct access to insert silicone gel implants. It is not limited by the size of the implant, because the incision can be extended if necessary. It is also the most conservative approach relative to disturbing the breast parenchyma and preserving lymphatic drainage. The scars are usually of good quality and hidden under the brassiere (Fig. 25.6E). Correct planning of the incision is important to leave the final scar positioned right in the new inframammary fold. This approach can be indicated for every patient who is not a candidate for periareolar mastopexy, and for those patients with a previous history of hypertrophic scar or keloid. Disadvantages include a visible scar when the patient is lying down, greater risk of implant exposure compared to other approaches, and higher incidence of Mondor’s syndrome.¹¹

Fig. 25.6 A, C Preoperative and B, D, E postoperative views of a patient who underwent an inframammary subfascial breast augmentation (round, textured, 300 cc, high profile, silicone gel implant). E Postoperative view of the inframammary scar.

Implant selection is based mainly on the breast width, subcutaneous coverage, and the final aspect the patient would like to have. Measuring the breast width and reducing the subcutaneous thickness we define the approximate size of implant base. Depending on how natural or projected the patient wants her breasts to look like after surgery, we choose the implant profile. We have mostly been using round implants with a high or ultra-high profile. Subfascial anatomic implants or submuscular round implants have been indicated for patients with a thin subcutaneous coverage and those with risk of having postoperative rippling. Any size and shape (round or anatomic) of implants can be used in the subfascial plane, and inserted through any kind of the available incisions (axillary, periareolar, and inframammary approaches). However, attention should be paid when putting anatomic implants through a transaxillary incision, in order to avoid misplacement of the implant, which should have its major projection right in the lower poles. Regarding the implant size, we have been using an average of 250–300 cc implants. The largest implant we have already used was a round, high profile, 400 cc implant, inserted in the subfascial pocket though a transaxillary incision.

Operative Technique

Axillary approach

The axillary incision is placed in the local natural crease. An S-shaped, 4 cm long incision is performed in the main axillary fold, about 1 cm behind the lateral border of the major pectoralis muscle. It is important never to cross beyond the lateral edge of the pectoralis muscle. As we know, transaxillary breast augmentation can damage lymphatic vessels during subcutaneous tunnel dissection and insertion of the implant into the breast pocket. To minimize lymphatic injuries, subcutaneous tunnel should be dissected up to the superior lateral border of the muscle, preserving an inferior lateral triangle of soft tissue containing most of the lymphatic structures (Fig. 25.7).^9,10

Fig. 25.7 A Markings for transaxillary breast augmentation, limiting subcutaneous tunnel dissection superiorly and the inferior lateral triangle containing lymphatic structures. B Intraoperative details showing a lymphatic vessel adjacent to the subcutaneous tunnel and the implant inside the pocket.

The pectoralis fascia is incised, and a subfascial breast pocket is dissected with electrocautery. It can be done using an endoscopic retractor or through direct view using long lighted retractors (Fig. 25.8).

Fig. 25.8 Transaxillary subfascial breast augmentation. A Markings; B incision infiltration.C subcutaneous tunnel dissection; D opening pectoralis major fascia; E subfascial breast pocket dissected using long lighted retractor; F implant insertion; G subcutaneous tunnel dissected and the implant settled into the pocket; H immediate postoperative view.

Areolar approach

Periareolar breast augmentation can be performed with or without mastopexy. The skin is usually incised in the lower half of the areolar circumference, preserving the upper half as a superior pedicle for the nipple–areola complex. If a mastopexy is intended, a donut-area of skin is de-epithelialized, also preserving the upper half of the dermis. The inferior pole of the breast is dissected in an oblique direction, between the breast parenchyma and the subcutaneous tissue. Once the pectoral fascia is reached, it is incised approximately at the nipple level. The subfascial pocket is then created in all directions up to the marking limits (Fig. 25.9).

Fig. 25.9 Periareolar subfascial breast augmentation and mastopexy. A Markings; B periareolar de-epithelialization and lower half parenchyma access; C subfascial pocket created; D implant insertion; E periareolar round-block suture planning; F round-block suture tightened.

Another option of incision is the trans-areolar approach, which can be indicated for patients with an areolar diameter of at least 3.5 cm. A geometric broken line incision is done horizontally in the areola, merging and not transecting the nipple, without disturbing the lactiferous ducts or mammary gland.¹⁴ Dissection of the breast is performed as in the periareolar approach.

Inframammary approach

A 4-cm incision is made in the new proposed inframammary crease. The new inframammary fold and the incision should be carefully planned, in order to have a good quality and well placed scar. The site of the new inframammary fold and future scar should consider the implant diameter, the subcutaneous thickness, and skin elasticity. Gently stretching up the nipple–areola complex, the new inframammary fold distance from the nipple is marked adding the implant radius size and the subcutaneous thickness. This distance (nipple–new inframammary fold) usually ranges from 5 to 8 cm. After the skin and subcutaneous tissue are incised, the pectoral fascia is visualized and incised at the level of the areola, in order to create the subfascial pocket dissecting superior and inferiorly, as described above (Fig. 25.10).

Fig. 25.10 Inframammary subfascial breast augmentation. A Skin markings; B pectoralis fascia being lifted up; C implant inserted and fascia being closed; D immediate postoperative view.

Pitfalls and How to Correct

Implant displacement

This is a relatively common cause of postoperative asymmetries. They can be caused by mistakes and differences in the pocket dissection, early excessive movements with the arms, especially when implants are submuscular, and sleeping positions in early postoperative period. Anatomical implants should be placed with the most projected point in the lower pole of the breast. If not symmetrically settled into the breast pocket, or even if it rotates inside the pocket, differences in the breast shape, contour and projection may be visible. In our experience, smooth surface gel implants are more likely to suffer postoperative displacement, because it does not adhere to surrounding tissues and to the capsule as is expected with textured implants.

Mild cases of implant displacement can be managed conservatively using modeling bra, elastic bands and breast massages trying to compensate for the differences. This is even more difficult in patients with textured implants. More severe and long-term cases will probably need reoperation to reshape the breast pocket with extra dissections or sutures (Fig. 25.11). Sometimes a subclinical seroma and double capsule can cause anatomical implant rotations.

Fig. 25.11 Transaxillary correction of breast implant displacement: right implant moved superiorly and the left moved inferiorly. Implants were changed from submuscular to subfascial breast pocket. A, C Preoperative and B, D postoperative views.

Preoperative asymmetry

Differences in breast sizes can be usually handled by using different implant volumes (Fig. 25.12). However, if large volumes (more than 50 cc) are necessary to improve the asymmetry, attention should be given to the base diameter and projection of the implants to avoid other asymmetries. When concomitant mastopexy is performed, excessive tissue from the larger breast can be resected, and the same or similar size of implants used.

Fig. 25.12 A, C Preoperative and B, D postoperative views of a patient who underwent transaxillary, subfascial breast augmentation (anatomic shape, textured, CPG 321, 375 cc to the left breast and 290 cc to the right breast, high profile, silicone gel implant).

Tuberous breast

Cases of mild to moderate grades of tuberous breast can be managed properly with a transaxillary subfascial breast augmentation (Fig. 25.13). However more severe cases must be treated with periareolar and circumareolar surgical access.

Fig. 25.13 A, C Preoperative and B, D postoperative views of a patient who underwent a transaxillary correction of mild to moderate tuberous breast (anatomic shape, textured, CPG 323, 260 cc, high profile, medium height, silicone gel implant). E Note the markings of radial fascia and parenchyma incisions in the inferior pole of the breast to gain better projection and improve inferior pole hypoplasia.

Submuscular implant mobilization

In some cases in which the patient presents with displacement of the implant with contraction of the pectoralis muscle, it is possible to achieve a good postoperative result with the change of the implant to the subfascial pocket (Fig. 25.14).

Fig. 25.14 A, B Patient had a previous submuscular augmentation mammaplasty. The picture shows implants moving upward when pectoralis muscles contract. Implants were changed from submuscular to subfascial plane. C, D Postoperative views showing a correction of the distortion caused by pectoralis muscle contraction.

Thin patients and rippling

These patients represent a very challenging situation because of the absence of adequate tissue for covering the implant. We present a case that demonstrates the quality of natural contour with the utilization of the subfascial pocket. In a very small percentage of cases they can present with mild rippling that can be treated satisfactorily with fat grafting (Fig. 25.15).

Fig. 25.15 A, C Preoperative and B, D postoperative views of a thin patient who underwent subfascial breast augmentation (round, textured, 250 cc, high profile, silicone gel implant). E This very thin patient presented with some rippling in the upper pole of the breasts. This area is now being treated with local fat grafting.

Capsular contraction

Capsular contraction still remains one of the most common and challenging problems after breast augmentation. Every technical detail is important to minimize its risk. We have routinely adopted some methods to help prevent postoperative capsular contracture. Some of these include:

• prophylactic intravenous antibiotic (cefazolin 1 g) during anesthesia induction;

• skin preparation with antiseptic chlorhexidine soap and chlorhexidine–alcohol solution;

• complete sterile technique;

• eletrocautery dissection to minimize bleeding in the pocket;

• avoiding the use of gauze or cotton pads to wipe the breast pocket, instead using normal saline irrigation;

• changing and washing the new gloves just before handling the implants;

• cleaning the skin around the incision with the antiseptic solution just before inserting the implants.

We have been trying to revert mild and moderate cases of capsular contracture (Baker II-III) with a relatively new class of anti-inflammatory drugs, the leukotriene inhibitor montelukast. This drug has been used for treatment and prevention of acute episodes of asthma. Some literature reports have suggested its inhibitory effect also on implants capsular contraction. Our clinical impression is also favorable, noticing smoother augmented breasts after starting its use.

Reoperation is still indicated for severe and non-reversible cases of capsular contracture. Depending on capsule thickness and restriction to the implant, capsulotomy (relaxing incisions), or partial or complete capsulectomy (capsule resection) can be performed (Fig. 25.16).

Fig. 25.16 Periareolar correction of bilateral capsular contracture by removing the implants and placing them into a subfascial pocket: A, C preoperative and B, D postoperative views.

Postoperative Care

Patients are usually discharged the same day of surgery, only taking pain medications. It is recommended to use a compressive brassiere and if the approach is transaxillary an elastic band is used on the upper pole of the breast and over the axillary tunnel for 1–2 weeks to avoid hematoma and seroma. An antiseptic soap of chlorhexidine is used when showering, and some gauze pads protect the wound while wearing the bra and the elastic band. In general, regular movements of the arms are allowed after 1 week, driving after 1–2 weeks, aerobic exercises such as jogging after 1 month, and lifting weights with the arms after 2 months.