Muscle-Splitting Breast Augmentation: A New Pocket in a Different Plane

Background Breast augmentation usually is performed in subglandular, subfascial, or partial submuscular pockets, including the dual plane. A new pocket has been described and used by the author. The initial pocket was made in the subglandular plane up to the lower level of the nipple–areolar complex, and the submuscular plane was reached by splitting the pectoralis major muscle without its release from the costal margin. The implant lies in this plane simultaneously behind and in front of the pectoralis. Methods From October 2005 to November 2006, 125 patients underwent bilateral breast augmentation using the new technique. Soft cohesive gel microtextured round implants ranging in size from 230 to 440 ml were used. Results All the patients experienced a quick recovery with three-dimensional enhancement and having the benefits of both subglandular and submuscular planes. No rippling, lateral displacement, double-bubble deformity, or muscle contraction–associated deformities were seen. All the patients had aesthetically natural cleavage, with the nipple at the most projected part of the breast. Postoperative analgesia requirements were reduced because of dissection in natural planes. Conclusion For adequate cover of the prosthesis, only the upper part of the pectoralis major muscle is required. This can be achieved by using the pectoralis muscle-splitting technique. The pectoralis major was split in the direction of its fibers, avoiding extensive muscle release. Surgical morbidity was reduced, resulting in a quick postoperative recovery and a more natural three-dimensional appearance of the breast. Oral presentation at the 6th Croatian Congress of Plastic, Reconstructive, and Aesthetic Surgery, Optija–Rijeka, Croatia, 6–11 October 2006     

Subfascial Breast Augmentation: A Comprehensive Experience

Background  

Subfascial breast augmentation, first performed by Dr. Ruth Graf in 1998, places the implant above the pectoralis muscle but below the pectoralis fascia. Graf documented that this approach resulted in less capsular contracture than subglandular implant placement and a more natural shape while eliminating implant animation with arm movement. In addition, implant edge visibility was decreased compared with subglandular implantation in all but the extremely thin patient. Because of the described benefits and high patient satisfaction, the authors began to perform this technique in 2006.     

Anatomic and Physiologic Advantages of Totally Subfacial Breast Implants

For the past 4 years, whenever it was possible to choose between the subglandular or the submuscular location for the implant pocket (in cases with no precise indication for the submuscular location), the authors have opted for the totally subfascial plane (subaponeurotic) to avoid the disadvantages of the other locations and to obtain additional benefits. The subfascial plane lies below the deep thoracic fascia, or deep aponeurosis, which is not only that of the pectoralis (the muscle connecting with the breast in its upper two-thirds only). The implant is placed completely beneath this fascia, which covers, in addition to the pectoralis major muscle, the serratus, the lateral oblique, and the rectus anterior muscles. This study included 100 women who had breast implanted in the subfascial (subaponeurotic) plane. Of these women, 63 were thin patients with little fatty tissue. Textured surface implants were used McGhan style 120 and 110. All procedures were approached through an inferior periareolar incision. Excellent coverage of the implant as well as natural shape and mobility was achieved for all patients. No rippling in the upper half was observed. Two patients had Baker grade 2 capsular contracture (2%). No seromas or infections were seen, and only once was a surgical exploration necessary for excess drainage volume (1%). In the immediate postoperative period, less edema was recorded and recovery was faster than with the other two procedures: submuscular and subglandular. When circumstances indicate a subglandular pocket, the subfascial plane would seem to be the logical place for mammary implants.     

Endoscopic breast subpectoral augmentation for second-degree breast ptosis

Glandular ptosis and first-degree ptosis are treated routinely with breast augmentation in select patients. Second-degree ptosis is difficult to treat with breast augmentation alone. Patients must be well informed and selected properly to obtain a satisfactory result. Historically, second-degree ptosis is treated most commonly with subglandular augmentation. The authors demonstrate that second-degree ptosis may be treated using endoscopic subpectoral augmentation. They think that the endoscopic approach gives more control and precision in the lowering of the inframammary fold and the placement of the implant. Additionally, there may be a decrease or maintenance in the distance from the clavicle to nipple because of shortening the pectoralis major as a result of dividing it from the sixth rib at the sternal attachment laterally to the serratus fascia.     

The “Shirt Pocket” Technique—An Alternative for Augmentation-Mastopexy

Augmentation-mastopexy is a frequent procedure with high rates of early recurrence of breast ptosis, mainly after subglandular approach. The dual-plane techniques, based on the cranial dissection of the pectoralis, is the most used, but this plane does not cover the inferior pole of the breast. Then, the possibility of a downward dissection of the muscle seems to be more reasonable to retain the implant and improve postoperative results. This study aimed to review the anatomy of the pectoralis in cadavers and the use of its downward dissection to create a pocket for breast implant as a “shirt pocket.” This maneuver was associated with a superior-based dermoglandular flap to overprotect the inferior pole. No complications were related in the postoperative period. The anatomic review showed that the “shirt pocket” is a safe option if done carefully. The technique demonstrated to be feasible and seemed to be effective, being another alternative to prevent early recurrence of breast ptosis in these procedures.     

Subpectoral breast augmentation through the abdominoplasty incision

Abdominoplasty and breast augmentation are often performed together, and subglandular augmentation through the abdominoplasty incision has been previously described. Nine cases of subpectoral breast augmentation and abdominoplasty performed through a single low transverse abdominal incision were performed between 2002 and 2005. The selection criteria included women who were healthy, nonsmokers, without true breast ptosis or breast deformity requiring additional shaping. The subpectoral space was accessed and the pectoralis major origins were mobilized under direct vision, and the implant pocket was shaped with the aid of a breast sizer and breast dissector. The mean follow-up was 22 months. The surgical goals were realized in all cases, with no asymmetry or implant-related complications. The standard abdominoplasty incision provides ample exposure for the creation of a subpectoral pocket and precise placement of implants. The procedure should be considered in patients who wish abdominal recontouring and breast augmentation and have minimal ptosis.     

Anatomic and physiologic advantages of totally subfascial breast implants

For the past 4 years, whenever it was possible to choose between the subglandular or the submuscular location for the implant pocket (in cases with no precise indication for the submuscular location), the authors have opted for the totally subfascial plane (subaponeurotic) to avoid the disadvantages of the other locations and to obtain additional benefits. The subfascial plane lies below the deep thoracic fascia, or deep aponeurosis, which is not only that of the pectoralis (the muscle connecting with the breast in its upper two-thirds only). The implant is placed completely beneath this fascia, which covers, in addition to the pectoralis major muscle, the serratus, the lateral oblique, and the rectus anterior muscles. This study included 100 women who had breast implanted in the subfascial (subaponeurotic) plane. Of these women, 63 were thin patients with little fatty tissue. Textured surface implants were used McGhan style 120 and 110. All procedures were approached through an inferior periareolar incision. Excellent coverage of the implant as well as natural shape and mobility was achieved for all patients. No rippling in the upper half was observed. Two patients had Baker grade 2 capsular contracture (2%). No seromas or infections were seen, and only once was a surgical exploration necessary for excess drainage volume (1%). In the immediate postoperative period, less edema was recorded and recovery was faster than with the other two procedures: submuscular and subglandular. When circumstances indicate a subglandular pocket, the subfascial plane would seem to be the logical place for mammary implants.     

Complete Submuscular Breast Augmentation: 650 Cases Managed Using an Alternative Surgical Technique

Background An alternative complete submuscular surgical technique for primary breast augmentation is presented. Since 1998, the author has refined the procedure for total submuscular placement of textured silicone gel implants, with good results for more than 650 patients. Methods The submuscular plane is accessed via a semicircular periareolar incision. Round or anatomic implants are placed beneath the pectoralis major and external oblique muscles, the rectus sheath, and the serratus anterior muscle fascia, which together create a contiguous structure that completely separates the implant from the breast tissue. Results High-riding implants were the main complication in early cases, through creation of an insufficiently large submuscular pocket. Only a very low incidence of Baker II capsular fibrosis was observed, and there were no Baker III or IV capsular contracture revisions. There were no cases of infection or “bottoming out.” Areolar scarring was well concealed, and rippling and implant distortion were virtually nonexistent. Even in thin women, the implant edge was scarcely visible or palpable. Patient satisfaction levels were very high, with the majority viewing the implants as their own tissue in terms of natural feel and appearance. Conclusions The advantages of the described surgical method are several-fold, particularly for lean patients. It offers a promising alternative to subglandular and partial submuscular implant placement and to other total submuscular techniques for primary breast augmentation. Furthermore, it provides a solution for tuberous and ptotic breasts, coupled with mastopexy as required, and good results have been achieved with correctional surgery for subglandular capsular contracture, bottoming out, and rippling.     

Experience of 1000 Cases on Subfascial Breast Augmentation

Background  

Throughout the years the female breast has been manipulated through aesthetic and reconstructive surgery. Since the 18th century there have been reports of techniques that have tried to increase the volume of the mammary gland. This article demonstrates a technique for increasing the volume of the mammary gland by dissection of the fascia of the pectoralis major muscle. This technique provides long-term results due to the optimized dynamics between the soft tissue and the implant. The subfascial technique is paramount to the subglandular method because primarily it offers better palpable firmness in the periareolar area, a significant decrease in the step effect produced by an excessive projection of the breast, a favorable gravitational pull of the breast, and a considerable reduction in the incidence of capsular contractures. The movement of the implant, postsurgical pain, and bleeding caused by the incision of the pectoralis muscle diminish with this technique. Because of the fascia’s tendency to be preserved, this procedure has the advantage of being able to be applied where previous surgery has been performed; this concedes the subfascial technique a more versatile angle.     

Advantages and Outcomes in Subfascial Breast Augmentation: A Two-Year Review of Experience

BACKGROUND: One of the most popular surgical cosmetic procedures, breast augmentation, has enjoyed large acceptance in the last few decades. One of the most important factors in the dynamics established between the implants and the soft tissues after breast augmentation is the pocket plane. Surgeons have been seeking the proper plane into which the implant might be placed. The subglandular approach resulted in implant edge visibility and was thought to result in a higher incidence of fibrous capsular contractures. Despite the advantage of concealing the implant edges using the subpectoral approach, implant displacement occurred with contraction of the pectoralis muscle. The use of the retrofascial plane seems to yield the benefits of both planes without the deficits. METHODS: Since 2006, 45 patients with hypomastia have undergone subfascial breast augmentation using anatomical contour profile gel cohesive III textured implants. RESULTS: Pleasing long-term results have been obtained by using subfascial breast augmentation, with maintenance of a natural breast shape and a smooth transition between the soft tissue and implant in the upper pole. There were no capsular contractures and no complaints regarding displacement of the implants with contraction of the pectoralis major muscle. CONCLUSIONS: The subfascial breast augmentation technique offers improved long-term aesthetic results because the dynamics between the implant and soft tissues have been optimized. This technique is extremely versatile and may also be used in patients requiring removal and replacement of breast implants.     

Synmastia: prevention and correction

Synmastia is a condition of aberrant communication of the breasts. Apart from the rare congenital cases, this is usually a result of technical complications during breast augmentation surgery caused by an overdissection at the medial side of the pocket, over the sternum, in the subglandular plane; or overdivision of the major pectoralis muscle insertion along the sternum, in the submuscular plane. A multidatabase search about synmastia has been performed. Between November 2004 and April 2009, the senior author (G.S.) has performed 924 breast augmentations and his experience in preventing synmastia is discussed and compared with the literature. Accurate surgical plan, correct choice of implants' size, and correct surgical technique are the most important rules to prevent synmastia. It is difficult to correct synmastia: additional reoperations expose patient to risks, cost, and dissatisfaction. On the basis of the recent literature and personal experience, we propose some classifications and guidelines to prevent synmastia.     

Results of subglandular breast augmentation using a new classification method--18-year follow-up

The main problem after augmentation mammaplasty is the formation of capsular contractures. The frequency of this complication varies in different reports. In this study the results in 60 women 15-21 years after subglandular breast augmentation are presented. The patients completed a questionnaire and the breasts were judged according to a new Breast Augmentation Classification (BAC) scale. Of all breasts examined 79% had grade III or IV, but 77% of the patients were satisfied with the final result. However, 84% thought that their breasts were too hard. Breast cancer had not developed in any patient. Rheumatoid arthritis developed in one patient 4 years after the operation. Capsular contracture and unacceptable results after subglandular breast augmentation were found in the major portion of the patients in this study.     

The double pocket technique: aesthetic breast augmentation

A subglandular versus a subpectoral pocket for breast prostheses has been a subject of discussion over the past quarter century. In 1994, in order to increase the volume, enhance the shape, and improve the breast projection, the authors [1,2,3][1-3] used a procedure that took advantage of the virtual spaces found in the breast anatomy, simultaneously utilizing the subglandular and subpectoral areas by locating the prostheses in a double pocket on both sides of the pectoral muscle, joined through a gentle muscle buttonhole.     

Treatment of the Fibrous Capsule on Mammary Implants: A Technical Innovation for Changing the Implant from the Subglandular to the Submuscular Plane

The details and technical resources used in changing subglandular implants with fibrous capsules to the submuscular plane are described. A simple technique is proposed involving explantation followed by a partial capsulectomy that leaves in its place a patch from its deep plane that is adherent to the pectoralis muscle. This patch can be used as an access to the retromuscular space with no injury to the muscle. It finally will be expanded as a mesh to allow a normal projection of the implant.     

A new method of modified radical mastectomy for breast cancer

We have developed a new type of modified radical mastectomy, the method and clinical results of which are reported herein. In this operation, axillary dissection is performed by the following two approaches. Firstly, the axillary contents are dissected from the highest possible subclavicular point to the pectoralis minor muscle, after partially cutting the sternocostal origin of the pectoralis major muscle. The second approach is from the posterior aspect of the pectoralis minor muscle to the lateral portion of the latissimus dorsi muscle. Parasternal dissection can also be performed for stage II and IIIa cancers with a central or medial tumor. After lymph node dissection, the detached edge of the sternocostal origin of the pectoralis major muscle is resutured to cover the parasternal region. Thus, complete dissection of the axillary nodes is performed whilst preserving the pectoralis major and pectoralis minor muscles. Good clinical results were achieved with respect to radicality, cosmetic effects and function in 28 patients with stage I, II, and IIIa breast cancers who were followed up for between 5 to 8 years. This new operation may therefore be adopted for the majority of patients with Stage I, II, or IIIa cancers, unless massive infiltration into the pectoralis major muscle has occurred. Preservation of both the pectoralis major and pectoralis minor muscles results in a good cosmetic appearance, good functioning of the arm and easy reconstruction of the breast following mastectomy.     

A new method of modified radical mastectomy for breast cancer

We have developed a new type of modified radical mastectomy, the method and clinical results of which are reported herein. In this operation, axillary dissection is performed by the following two approaches. Firstly, the axillary contents are dissected from the highest possible subclavicular point to the pectoralis minor muscle, after partially cutting the sternocostal origin of the pectoralis major muscle. The second approach is from the posterior aspect of the pectoralis minor muscle to the lateral portion of the latissimus dorsi muscle. Parasternal dissection can also be performed for stage II and IIIa cancers with a central or medial tumor. After lymph node dissection, the detached edge of the sternocostal origin of the pectoralis major muscle is resutured to cover the parasternal region. Thus, complete dissection of the axillary nodes is performed whilst preserving the pectoralis major and pectoralis minor muscles. Good clinical results were achieved with respect to radicality, cosmetic effects and function in 28 patients with stage I, II and IIIa breast cancers who were followed up for between 5 to 8 years. This new operation may therefore be adopted for the majority of patients with Stage I, II, or IIIa cancers, unless massive infiltration into the pectoralis major muscle has occurred. Preservation of both the pectoralis major and pectoralis minor muscles results in a good cosmetic appearance, good functioning of the arm and easy reconstruction of the breast following mastectomy.     

Maximizing the use of precapsular space and the choice of implant type in breast augmentation mammaplasty revisions: review of 49 consecutive procedures and patient satisfaction assessment

Background  

Capsular contracture, implant malposition and displacement, breast asymmetry, improper contour, and symmastia may compromise the aesthetic outcome of breast augmentation and usually require surgical correction. Correction of these deformities may be achieved by accommodating a new implant in a novel pocket created in the precapsular space in either the subpectoral or subglandular plane. This article describes a modality to correct adverse results of augmentation mammaplasty and evaluates patient satisfaction.     

胸大肌筋膜在乳腺癌乳房切除后即刻乳房重建中的应用

目的:探讨胸大肌筋膜在乳腺癌乳房切除后即刻乳房重建中的应用价值。方法:回顾分析2014年5月—2016年9月接受保留乳头乳晕复合体的皮下腺体切除与即刻乳房重建的18例早期乳腺癌患者临床资料。患者均采用胸大肌及其筋膜覆盖并包裹假体行乳房重建,即首先从自胸骨旁及锁骨下向外侧游离剥离胸大肌筋膜,然后在胸大小肌之间植入假体,最后用游离的胸大肌筋膜缝合胸大肌外侧缘,牢固包裹假体。结果:18例乳房重建手术均取得成功,经过12~40个月随访,所有患者未发现复发、转移,重建乳房对称性好、形态自然,未发现假体移位、挛缩,术后外观评价优良率100%。结论:对于部分早期乳腺癌患者,实施保留乳头乳晕复合体的皮下腺体切除、利用胸大肌及其筋膜覆盖假体的即刻乳房重建方法简单易行,重建乳房美容效果好,并发症少。     

Augmenting the narrow-based breast: The unfurling technique to prevent the double-bubble deformity

Routine subpectoral or subglandular mammary augmentation in women with a small breast (particularly lower pole deficiency) often results in poor late results with the appearance of a double-bubble deformity. We describe our experience with a technique of unfurling the breast tissue at augmentation in an effort to avoid this complication and improve the long-term results.