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.     

Breast augmentation: a review of subglandular and submuscular implantation

A study of 156 patients who underwent augmentation mammoplasty at the Medical College of Georgia from June 1980 to July 1985 is presented. Complete records on 89 patients with 196 implants were obtained. A retrospective analysis with respect to capsular contracture was undertaken. Possible influential variables including age of patient, type of prosthesis, operative blood loss, use of local steroids, and site of insertion (i.e., submuscular versus subglandular) were considered. The site of implant insertion was the only statistically significant factor affecting capsular contracture. The incidence of capsular contracture was 9.4% with the submuscular approach and 58.0% with subglandular contracture. The followup time for the submuscular group was 17.4 months (range of 6-36 months) with the mean time of capsule contracture occurring 4.5 months after insertion. There were no significant differences in intraoperative blood loss or elapsed operating time between the submuscular and the subglandular placements of the prosthesis. This study confirms the submuscular technique of augmentation mammoplasty as the most reliable method of reducing the high incidence of capsular contracture.     

Breast augmentation: A review of subglandular and submuscular implantation

A study of 156 patients who underwent augmentation mammoplasty at the Medical College of Georgia from June 1980 to July 1985 is presented. Complete records on 89 patients with 196 implants were obtained. A retrospective analysis with respect to capsular contracture was undertaken. Possible influential variables including age of patient, type of prosthesis, operative blood loss, use of local steroids, and site of insertion (i.e., submuscular versus subglandular) were considered. The site of implant insertion was the only statistically significant factor affecting capsular contracture. The incidence of capsular contracture was 9.4% with the submuscular approach and 58.0% with subglandular contracture. The followup time for the submuscular group was 17.4 months (range of 6–36 months) with the mean time of capsule contracture occurring 4.5 months after insertion. There were no significant differences in intraoperative blood loss or elapsed operating time between the submuscular and the subglandular placements of the prosthesis. This study confirms the submuscular technique of augmentation mammoplasty as the most reliable method of reducing the high incidence of capsular contracture.Presented at the annual meeting of the Southeastern Society of Plastic and Reconstructive Surgery, Boca Raton, Florida, May 27, 1986     

Endoscopic Transaxillary Subglandular Breast Augmentation Using Silicone Gel Textured Implants

We present our experience with endoscopic transaxillary subglandular breast augmentation using textured silicon gel implants. Fourteen implants were placed in seven patients through a 4 cm axillary incision, in a subglandular pocket, with the help of a 10 mm, 30° endoscope with a subcutaneous retractor and endoscopic diathermy. The implant was inserted with the help of a plastic bag. No drains were left in place. The duration of the procedure was 1 h 30 min in the most recent cases. Bleeding during surgery was kept to a minimum, and there were no complications such as capsular contracture, hematoma, or hypertrophic scar. Infection occurred in one implant and it was necessary to extract it. This technique is an excellent tool for patients requiring subglandular implants who prefer a distant incision. It provides good control over dissection and allows the use of silicone gel implants, thus avoiding the risk of deflation. In addition, recovery is faster and there is less bruising and pain.     

Sub-muscular plane for augmentation mammoplasty patients increases silicone gel implant rupture rate

Background

Breast augmentation is one of the most common aesthetic procedures performed worldwide. One of the worst associated complications is implant rupture, a topic that will be addressed in the present study. The risk of developing silicone gel breast implant rupture following breast augmentation is associated with multiple factors, including: older generation implant, increased implant age, implant type, specific manufacturer, severe capsular contracture (Baker grade III or IV), and the presence of local symptoms. We hypothesize that the plane of the implant placement may also play a role in the development of implant rupture due to differences in opposing forces upon the implant between submuscular and subglandular planes.

A meta-analysis of optimum plane placement and related morbidity in primary breast augmentation

Despite extensive clinical experience of breast implants, there is continued controversy regarding the optimum placement of the prosthesis. More importantly, there is insufficient data to accurately determine whether subglandular (SG) or submuscular (SM) placement of the prosthesis diminishes postoperative complications. A search of published trials (n = 34) examined complication rates following SG and SM implant placement was conducted. Pubmed (MEDLINE) database was used and the available data was then cross-referenced. Eligible trials (n = 6) were then reviewed and selected data extracted. Primary outcomes measured were postoperative haematoma, infection, capsular contracture and implant migration. 3603 patients were identified from relevant trials examining postoperative complication rates for both subglandular and submuscular implant planes. The submuscular implant plane was associated with a higher incidence of postoperative haematoma (OR 2.87, 95% CI, 1.44-6.11). The incidence of capsular contracture (OR 4.77) is more common when a subglandular plane is used. No significant difference was noted in the rate of postoperative infection (OR 1.20, 95% CI 0.57-2.58) or implant migration (OR 1.56, 95%CI 0.12-87.4) between the two groups. This meta-analysis confirms that subglandular augmentation results in lower short-term morbidity; however, submuscular placement appears to provide the best long-term outcome in terms of morbidity. In the absence of randomized controlled trials comparing these two techniques, this meta-analysis provides evidence to guide surgeons to achieve the best outcomes for their patients.     

Does the Surface Structure of Implants Have an Impact on the Formation of a Capsular Contracture?

Background The formation of a fibrous capsule around a silicone breast implant is part of a physiologic foreign body reaction after breast augmentation. In contrast, the formation of a capsular contracture is a local complication of unknown cause. This study aimed to discover whether the surface structure of the implant (textured vs smooth) has any impact on the formation of a capsular contracture. Methods This prospective study included 48 female patients with unilateral capsular fibrosis grades 1 to 4 in Baker’s clinical scaling system. Of these patients, 14 received implants with a textured surface (Mentor), and 34 received implants with a smooth surface (Mentor). The implants all were placed in a submuscular position by the same experienced plastic surgeon. The clinical data were assessed using standardized patient questionnaires. For histologic diagnosis, operatively excised capsular tissue was examined. Preoperatively, venous blood samples for determining serum hyaluronan concentrations were taken from the patients. The control group consisted of 20 patients without capsular fibrosis. Results The separate analysis of clinical data for the patients with textured and those with smooth-surfaced breast implants showed a slightly reduced degree of symptoms for the patients with textured silicone breast implants, as compared with those who had smooth-surfaced implants. The histologic assessment of the fibrosis showed a symmetric distribution for Wilflingseder scores 1 to 3 (29% each), whereas 13% of the capsular tissues could be assigned to Wilflingseder score 4. In contrast, the histologic assessment of the patients with smooth-surfaced implants predominantly showed a Wilflingseder score of 3 (65%). The serologic investigations via enzyme-linked immunoassay (ELISA) showed serum hyaluronan concentrations of 10 to 57 ng/ml (25.0 ± 11.7 ng/ml). Therefore, no statistically significant differences in terms of serum hyaluronan levels could be determined between the two groups of patients. In comparison with the control group, the patients with implants showed elevated serum hyaluronan levels (p < 0.05). Conclusions The histologic examination and serum hyaluronan concentration analysis showed no statistically significant difference between smooth-surfaced and textured implants (Mentor) with respect to the development of capsular contracture. On the other hand, the severity of capsular contracture showed a positive linear correlation with the degree of local inflammatory reactions, which were independent of the implant surface.     

The role of endoscopy and implant texture in transaxillary submuscular breast augmentation

In 1996 the authors reported their experience with 92 consecutive patients undergoing traditional (nonendoscopic) transaxillary submuscular breast augmentation. They reported a capsular contraction rate of 1.1% using textured saline implants, as well as an implant malposition rate of 8.6%. At that time they hypothesized that "the endoscope will lessen the rate of implant malposition." To clarify the role of implant texture and to justify the use of endoscopic techniques in transaxillary submuscular breast augmentation, the authors have studied an additional 58 consecutive patients with two significant changes. First, the endoscope was used to dissect the implant pocket in each patient. Second, smooth-wall implants were substituted for the previously used textured implants. Their rate of implant malposition dropped significantly, from 8.6% to 2.0% (p = 0.10), and their capsular contraction rate remained low, at 2.0% (p = 0.63). They conclude that direct endoscopic control improves implant positioning in the transaxillary submuscular operation, and implant texture does not improve capsular contraction rates when the prosthesis is placed in the submuscular position.     

Combining muscle-splitting biplane with multilayer capsulorrhaphy for the correction of bottoming down following subglandular augmentation

Implant malplacement is the second most common reason for revision and bottoming down is the most common presentation of implant malplacement. Submuscular biplane relocation was combined with capsulotomies and multilayer capsulorrhaphy when bottoming down was seen following subglandular breast augmentation. Between 2005 and 2009, bottoming down following subglandular mammoplasty was seen in 41 breasts (19 bilateral and three unilateral). Of the 19 patients, 12 had downward transgression of inframammary crease (IMC) alone; this also included a patient with vertical scar mastopexy. Two patients had multiplane malplacements where bottoming down was associated with lateral displacement (telemastia) in one and medial displacement (symmastia) in the other. Two had simultaneous downward transgression of the IMC and nipple areolar complex (NAC) and three had bottoming down with capsular contracture independent of NAC descent. Follow-up of up to 3 1/2 years showed stable IMC and NAC relationship with acceptable results. Dog ear revision was required in one patient when IMC relocation was accompanied with vertical scar mastopexy and one patient needed revision for further relocation and improvement of symmastia. No wound breakdown or periprosthetic infection was seen in their series. Multilayer capsulorrhaphy with submuscular biplane repositioning of implants is a suitable option to correct bottoming down following subglandular augmentation.     

Breast Implant Stability in the Subfascial Plane and the New Shaped Silicone Gel Breast Implants

The author presents his experience with breast augmentation using a next-generation, form-stable, anatomically shaped silicone gel breast implant. Rotation is a potential complication for anatomically shaped breast implants. Anatomically shaped saline implants have been reported to have a rotation rate as high as 14%, while lower rotation rates of 1–2.6% for anatomic cohesive gel silicone implants have been reported. Currently, these implants are limited in the United States to US FDA-approved clinical trials. The author reviews the appropriate surgical techniques to prevent rotation when using these devices. A recent innovation, placement of the superior pole of the implant underneath the superficial fascia of the pectoralis major muscle, is described. Primary and secondary breast augmentations in 241 procedures using the Allergan Style 410 implant resulted in a 0.0% rotation rate. Overall, the anatomic form-stable silicone gel breast implants, when placed subfascially, improve common complications such as capsular contracture and implant rupture with improved aesthetic outcomes and patient satisfaction.     

Revision augmentation mastopexy: indications, operations, and outcomes

In the absence of any published information on the indications, frequency, and outcomes of revision augmentation/mastopexy, an 8-year retrospective review was undertaken of all patients undergoing revision of a previous augmentation/mastopexy in the senior author's practice. The data collected included original implant type, location and mastopexy type, indication for revision, interval from original surgery, new implant type, location, and associated corrective surgical procedures. A simultaneous review was also performed of all primary augmentation/mastopexies done during the same period.Twenty patients underwent revision of 34 previously performed augmentation/mastopexies. Five patients underwent revisions of a prior revision. Fourteen were bilateral, while 6 were unilateral, for a total of 34 breasts. Forty patients underwent primary augmentation/mastopexy during the same period. Among the revisions, 10 implants were originally subglandular, while 24 were either partly or totally submuscular. Twelve of the previous mastopexies were periareolar, 2 were vertical, and 20 were of the inverted T-type. The indications for revision included capsular contracture in 11 of 20 (55%) patients, nipple ptosis in 11 of 20 (55%) patients, implant malposition in 7 of 20 (35%) patients, dissatisfaction with implant size in 6 of 20 (30%) patients, poor scar in 5 of 20 (25%) patients, breast ptosis in 4 of 20 (20%) patients, nipple malposition in 2 of 20 (10%) patients, and patient preference in 1 of 20 (5%) patients. Most patients had 2 or more indications for revision. The average duration to revision was 7 years. In 13 of 20 (65%) patients, no change in implant type was made. The remainder had exchanges to a different type. In 12 of 20 (60%) patients, no change in implant location was made, whereas 8 of 20 (40%) patients had a change to the subpectoral or dual plane position. In 18 of 20 (90%) patients, the revision included the same type of mastopexy, while in 2 of 20 (10%) patients, the type of mastopexy was changed. Corrective surgical procedures performed included repeat mastopexy, capsulectomy, change of implant type, change of implant location, change of implant size, capsulotomy, capsulorrhaphy, and scar revision. To date, all of the patients are satisfied with their appearance. Follow-up ranged from 2 months to 4 years.Revision augmentation mastopexy is not an uncommon procedure, occurring half as often as primary augmentation/mastopexy in our series. There were 8 common indications for revision, with capsular contracture and recurrent ptosis being the most common. Eight surgical procedures, in various combinations, were performed during revision, with repeat mastopexy being the most common.     

Buckled Upper Pole Breast Style 410 Implant Presenting as a Manifestation of Capsular Contraction

Recent experience with the cohesive gel implant has shown an interesting variation of capsular contracture. Instead of spherical contraction, the capsule formation around the 410 implant seems to cause a buckling of the superior pole of the implant. This buckling has been observed in four implants and presented clinically in 2 of 50 patients with a superior pole mass. The capsular contraction around the implant and the buckling are probably camouflaged by a subpectoral implantation and this presentation should be recognized by the surgeon, especially when considering placement of the cohesive gel implant in a subglandular position. Histological sections of a capsule around the implant show fragmented silicone, with a cellular reaction around the fragmented silicone.     

The management of severe capsular contractures following breast augmentation

Several patients with severe capsular contracture following conventional augmentation mammoplasty with subcutaneously placed implants have had substantial improvement by replacing the implants in a submuscular position.     

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.     

Silicone gel implants in breast augmentation and reconstruction

Silicone gel implants have been widely used for breast augmentation and reconstruction since the 1960s. Several alterations to both elastomer shell and filler gel have been made over the years to improve their ability to replicate the natural breast and to decrease the incidence of capsular contracture. The latter is a pathologic process involving the periprosthetic tissues formed in response to the presence of the implant. When severe, capsular contracture may cause firmness, distortion, and pain. In response to many claims of implant-related connective tissue disease, the US Food and Drug Administration placed a moratorium in 1992 on silicone gel breast implants for cosmetic purposes. Despite a preponderance of scientific data to their safety, silicone gel implants are presently available in the United States only as part of limited clinical trials. They continue to be used in Europe and other parts of the world.     

Submuscular Periareolar Approach to Augmentation Mammoplasty in Korean Women

Augmentation mammoplasty can be approached by various methods according to the type of implant and implantation site depending on the status of the patient or surgeon's preference. The advantage for submuscular placement is based on problems associated with subglandular placement, especially capsular contracture and sensory changes in the nipple, and interference with the interpretation of mammograms is avoided. There are fewer complications such as hematoma, infection, and extrusion of the implant with submuscular dissection and relatively avascular, minimal sensory changes in the nipple compared with subglandular approach. The submuscular periareolar approach to augmentation mammoplasty was first described in the 1970s. This approach provides easy access to both the subglandular and subpectoral planes. It also provides a central point of access for creation of the implant pocket, which allows for easier and more accurate dissection in all diameters. The resultant periareolar scar is usually minimal with less injury to breast parenchyme and eventual biopsy or mastectomy incision to be performed through or around the areola. During the period of March 1999 to January 2000, 19 cases of who received submuscular periareolar augmentation mammoplasty under general anesthesia resulted in favorable scars with accurate access to pocket margin, easier dissection, and less bleeding compared with submuscular transaxillary augmentation mammoplasty. In our experience with the submuscular periareolar approach to breast augmentation it was highly versatile, safe, and less painful; postoperative hematoma incidence was greatly reduced and breast tissue injury was minimized.     

Textured or smooth implants for breast augmentation? A prospective controlled trial

This study examines the hypothesis that textured surface silicone implants reduce the incidence of adverse capsular contracture in breast augmentation. A total of 53 patients were entered into a prospective study; they were randomly assigned to receive either smooth or textured implants which were placed in the submammary plane. Of these, 50 patients were assessed at 12 months by a panel of observers who did not know which type of implants had been used. Adverse capsular contracture (Baker grades 3 and 4) was found in 28 breasts augmented with smooth surface implants (58%) and in 4 breasts in the textured surface implant group (8%). This reduction in adverse contracture using textured surface implants was highly significant (p less than 0.0001). Careful trial design is essential in studies of this sort in order that we can obtain useful data regarding the causes and prevention of adverse capsular contracture.     

Mastectomy with breast reconstruction in previously augmented patients: indications for implant removal

Surgeons performing breast reconstruction in previously augmented patients can either leave the preexisting implant in place and incorporate the implant into the reconstruction, or remove the implant, usually performing an implant exchange. The focus of this study is to identify indications for implant removal in previously augmented patients undergoing mastectomy with breast reconstruction. We performed a retrospective chart review of patients who underwent breast reconstruction from 1997-2007 at University of Alabama, Birmingham Medical Center. Of these patients, 54 had previous augmentation with silicone or saline implants. Twenty-two of these underwent bilateral breast reconstruction, making a total of 76 reconstructed breasts. Patients were followed for a mean of 2.1 years (range 0.1-5.1 years). The mean body mass index was 23.0 (range 18-30). Implants were explanted in all but one patient. Reasons for implant removal or exchange included subglandular position (n = 39), aged silicone implant (n = 50), rupture or leak (n = 24), implant exposure (n = 1), and infection (n = 1). Some patients had more than one reason for explantation. We recommend removal of preexisting implants for patients who have implants in a subglandular position, ruptures or leaks, site infections, implant exposures, capsular contractures, pain, indolent seromas, aged silicone implants, poor cosmesis, plans for or history of radiotherapy, and close proximity of tumor to implant. We also remove implants to respect patient preferences and to achieve symmetry in our reconstruction. Consequently, we find in our practice that most of previously augmented patients who undergo breast reconstruction will also undergo implant removal.     

隆乳术切口和假体置放层次及手术剥离范围探讨

目的：探讨隆乳术的切口选择、假体置放层次和腔穴剥离范围。方法：于1996例9月至2001年9月间行隆乳术537例，选择三种手术切口；乳房下皱襞切口、乳晕切口、腋窝切口；假体置放于乳腺后间隙或胸大肌后间隙；胸大肌后间隙的剥离范围以第6肋间隙为下界。术后随访半年-5年。结果：术后乳房位置、形态、手感均满意511例（占95.2%）。结论：乳房下皱襞切口适于站立时乳房下皱襞明显或者乳房轻度下垂者；对于乳晕直径≥4cm的受术者，可采用乳晕缘内上或者内下弧形切口；腋下切口最为隐蔽，适于所有的受术者。假体置放于胸大肌后间隙具有手感更真实、不易形成纤维囊性硬变、不影响哺乳等优势。在胸大肌后间隙进行剥离，顺应乳房下皱襞韧带的解剖结构，将下界定于第6肋间隙。