Subfascial Breast Augmentation: A Comprehensive Experience

Aesth Plast Surg
DOI 10.1007/s00266-009-9466-1
ORIGINAL ARTICLE
Subfascial Breast Augmentation: A Comprehensive Experience
Joseph P. Hunstad • L. Shayne Webb
Received: 2 July 2009 / Accepted: 31 July 2009
Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2010
Abstract
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.
Methods This report presents a comprehensive review of
the aforementioned technique by describing a large series
of subfascial augmentations (inframammary, periareolar,
and endoscopic transaxillary) as primary procedures, secondary procedures, and operations with concurrent use of
mastopexy performed by a single surgeon using multiple
approaches. A patient satisfaction questionnaire was used
in addition to a detailed clinical assessment.
Results The results of this procedure were reproducible,
controllable, and predictable. The study demonstrated a
high degree of patient and surgeon satisfaction with few
complications, a low rate of capsular contracture, no evidence of breast animation with arm movement, excellent
lower pole coverage, and a brief recovery period.
J. P. Hunstad (&)
The Hunstad Center for Cosmetic Surgery, PA, 11208 Statesville
Road, Huntersville, NC 28078, USA
e-mail: jphunstad@gmail.com; jph1@hunstadcenter.com
L. S. Webb
Nirvana Plastic Surgery, 1331 44th Ave. North, Myrtle Beach,
SC 29577, USA
Conclusions Subfascial breast augmentation is a safe,
effective procedure allowing for predictable results with
excellent shape and longevity. For the properly selected
patient, this approach provides the benefits of subglandular
and submuscular placement without the disadvantages
associated with each.
Keywords
Breast augmentation Implant Subfascial
Cronin and Gerow [1] first introduced subglandular silicone implants in 1962. While providing a rapid recovery
and satisfactory breast shape, implant placement in this
location often has resulted in implant edge visibility and
allegedly has a relatively high incidence of capsular contracture [9, 12, 16]. In addition, the longevity of the desired
breast shape in this position has been less than with submuscular placement, and implant ptosis occurrence has
been a problem. This has been due, at least in part, to the
disruption of connective fibers between the deep layer of
the investing fascia surrounding the breast and the pectoralis fascia [11].
With the advent of subpectoral implant placement by
Dempsey and Latham [2] in 1968, less implant visibility, a
lower incidence of capsular contracture, and more robust
longevity of shape with lessened ptosis was observed.
However, undesirable superior displacement of the implant
and implant animation with arm movement was frequently
noted [12, 13].
In 2000, Tebbetts described a modification of the subpectoral implant placement: the dual-plane pocket technique [15]. The implant pocket allows for varying degrees
of submuscular and subglandular placement individualized
for each patient depending on his or her unique tissue
characteristics. The dual-plane pocket provides less
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Aesth Plast Surg
implant visibility, more shape longevity, and less superior
implant migration than complete submuscular placement
[10, 15]. However, undesirable implant animation and a
flattening effect of the implant beneath the muscle still
occurs and is bothersome to many patients [13].
A new location for breast implant placement was
described in 1998 by Graf, who began to perform breast
augmentation using subfascial breast implant placement.
She documented that this approach resulted in less capsular
contracture than subglandular implant placement and a
more natural shape while eliminating the implant animation with arm movement associated with submuscular
placement [4, 5]. In addition, implant edge visibility was
decreased compared with subglandular implantation for all
but the extremely thin patient [3].
We became aware of Dr. Graf’s technique through multiple presentations and publications. Because of the described benefits and high patient satisfaction, we began to
perform this technique in 2006. This procedure has now
become our preferred means of breast augmentation because
we also have realized the benefits Dr. Graf described.
There have been several substantial articles on subfascial breast augmentation [3–6, 8, 11, 12, 14]. From our
prospective study, we present a more comprehensive
review of this technique by describing a large series of
subfascial augmentations using multiple approaches
(inframammary, periareolar, and endoscopic transaxillary)
performed by a single surgeon as a primary procedures,
secondary procedures, and operations performed concurrently with mastopexy.
We implemented a patient satisfaction questionnaire in
addition to a detailed clinical assessment, demonstrating a
high degree of subjective patient and surgeon satisfaction
with objective breast augmentation outcomes. This is the
first reported use of subfascial augmentation performed
concurrently with purse-string mastopexy and implant
conversion from the submuscular to the subfascial location.
Materials and Methods
Preoperative Evaluation
Preoperative evaluation begins with the patient in the sitting position. Measurements are made from the nipple to
the sternal notch. The breast width is measured from the
medial to the lateral aspect of the breast mound. The degree
of breast ptosis is assessed, and a pinch test is performed to
determine tissue thickness superficial to the pectoralis
muscle and thus the adequacy of upper pole soft tissue
coverage. Finally, the patient is placed in the supine position for a full breast and axillary examination to rule out
any abnormal pathology.
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Breast augmentation options regarding incision placement and the suggested implant pocket are discussed with
the patient. A pinch test result less than 2 cm is considered
a relative contraindication to subfascial placement and an
indication for submuscular placement. For submuscular
placement, we perform augmentation using the dual-plane
technique to provide for more adequate upper pole coverage. Incision options, implant size, and the decision for
saline or silicone are driven largely by patient preference.
To keep the incision length within the hair-bearing axilla,
we prefer not to use the endoscopic transaxillary technique
for silicone implants larger than 350 ml.
Operative Procedure
Augmentation using the subfascial plane is similar to
submuscular or dual-plane augmentation with regard to
incision options. We perform subfascial augmentation
using inframammary, periareolar, and axillary incisions.
The incision location determines where the pectoralis
fascia is divided and elevated. Using the transaxillary
incision, a 2.5- or 3.5-cm incision (saline or silicone,
respectively) is made with a 15-blade scalpel in a natural
skin fold at the apex of the hair-bearing axilla, with care
taken not to cross the anterior axillary fold (Fig. 1). Once
the incision is through the skin, spreading dissection with
scissors is used to divide the pectoralis fascia in the axilla
in a direction toward the nipple (Fig. 2). Finger dissection
then is used to develop the subfascial plane approximately
5 cm inferiorly and medially to allow for insertion of the
endoscope in a defined pocket (Figs. 3, 4, 5).
All subsequent dissection is performed under endoscopic control using electrocautery in an arc traveling in a
medial to a lateral direction based on preoperative markings for implant placement defining the cleavage and the
new inframammary fold. To prevent lateral implant displacement, we do not dissect beyond the lateral aspect of
the pectoralis major muscle. Inflatable implant testers then
are used to determine adequacy of the dissection before
placement of the permanent implant.
Meticulous hemostasis is achieved with electrocautery.
The pocket is irrigated with antiseptic Technicare solution
(TECHNI-CAREÒ Surgical Scrub Care-Tech Laboratories,
Inc., Saint Louis, MO), and 15 ml of 0.5% Marcaine is
instilled for postoperative anesthesia. The implants are
placed using a ‘‘no touch’’ technique [7]. Closure is
accomplished with interrupted absorbable deep dermal and
running intracuticular sutures.
Periareolar and inframammary fold augmentations differ
only in the location of the incision and the place at which
the fascia is divided. The periareolar incision is performed
from 3:00 to 6:00 to 9:00 at the edge of the areola using the
15-blade scalpel. To ensure that the incision is placed
Aesth Plast Surg
Fig. 3 Use of finger dissection to develop the initial subfascial
pocket plane
Fig. 1 Finding the optimal location for the axillary incision. a
Finding the apex of the axilla. b Placement of the incision within an
axillary fold
Fig. 4 Insertion of the endoscope in a defined plane
Fig. 2 Division of the pectoralis fascia using scissors dissection
exactly at the edge of the areola, preoperative markings are
made while the patient is standing before incision infiltration is performed. If the incision is marked after local
infiltration, the edge of the areola can become indistinct,
resulting in an undesirable intra-areolar incision that can be
highly visible.
Electrocautery is used first to dissect several centimeters
inferiorly in the natural superficial plane to limit the
amount of direct dissection through the gland. The fascia
then is entered in a midclavicular location several centimeters inferior to the nipple. This lessens the risk of sensory loss. The inframammary fold incision divides the
fascia in a similar fashion. However, the fascia is divided in
a more inferior/lateral position. We make both incisions
through the fascia perpendicular to the direction of muscle
fibers.
Using electrocautery, dissection is performed moving
superiorly and then in an inferior-medial direction parallel
to the direction of muscle fibers, providing the most distinct dissection plane. With the transaxillary approach, it
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Aesth Plast Surg
Fig. 5 a, b Distinct subfascial plane using the endoscope
has not been necessary to close the fascia. However, we
close the pectoralis fascia with interrupted 2-0 Vicryl as a
distinct layer when the procedure is performed through the
periareolar and inframammary routes (Fig. 6).
Study Design
Between July 2007 and April 2009, 61 patients underwent
subfascial breast augmentation under general anesthesia. A
total of 31 patients underwent primary augmentation procedures for cosmetic correction of hypomastia. Of these
procedures, 8 were performed through a periareolar incision, whereas 12 were inframammary and 11 were transaxillary endoscopic augmentations. A total of 21 patients
underwent primary purse-string mastopexy for hypomastia
and grade 1 or 2 ptosis. One patient underwent right periareolar augmentation for hypomastia and left purse-string
mastopexy for grade 1 ptosis. One patient had conversion
from subglandular to subfascial placement, whereas seven
patients had conversion from submuscular to subfascial
placement. All the conversion patients wished to eliminate
breast animation caused by arm movement.
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Fig. 6 Closure of the fascia in a distinct layer. a Fascial edges in the
inframammary incision. b Closure using interrupted 2-0 Vicryl
Additionally, four patients were referred to us with various complications. One patient had a ruptured silicone
implant, and another patient desired correction of bilateral
‘‘double-bubble’’ deformity. Two patients had acquired
Baker 3 and 4 capsular contractures. Gel implants were
requested by 60 patients in our series, and 1 patient underwent a primary purse-string mastopexy with saline implants.
Two patients in our series required a redo purse-string
mastopexy for residual ptosis. Four patients underwent
capsulorraphies to correct lateral or inferior implant displacement. Two patients required return to the operating
room for unilateral hematoma evacuation, and one 18-yearold patient presented with new onset stretch marks after
transaxillary augmentation. No patients in our series
experienced a capsular contracture or infection.
A patient questionnaire and a physician assessment were
created to assess patient and provider satisfaction (Figs. 7
and 8). All the patients in this series were asked to return to
answer the patient questionnaire and to undergo clinical
assessment, breast examination, and postoperative photography. Follow-up evaluation was somewhat problematic
Aesth Plast Surg
Patient Questionnaire for Subfascial Breast Augmentation
Table 1 Patient questionnaire results averaged for all the patients
We are conducting a study in regard to patient satisfaction. Please take a few minutes to
complete the questionnaire.
Overall satisfactiona
9.3
How do you rate the following factors?
Overall appearance & shapea
9.3
Range 1-10 (1 being poor, 10 being excellent)
Pain with procedure
a
8.7
1. Overall satisfaction
Poor
Good
Excellent
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Symmetrya
9.1
Scarringa
9.0
2. Overall appearance & shape
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Softnessa
9.9
3. Pain with procedure
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Nipple sensitivitya
4. Symmetry
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Implant animation ‘‘jumping’’
5. Scarring
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Ripplingb
9.5
6. Softness
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Palpabilityb
9.5
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Discomfortb
9.8
7. Nipple sensitivity
Range 1-10 (1 being severe, 10 being none)
8. Implant animation “jumping”
Severe
None
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
9. Rippling
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
10. Palpability
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
11. Discomfort
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Fig. 7 Patient questionnaire
8.8
b
a
Range 1 (poor) to 10 (excellent)
b
Range 1 (severe) to 10 (none)
9.9
Table 2 Physician assessment results averaged for all the patients
Breast symmetrya
9.5
Breast shapea
9.5
Palpabilityb
9.5
b
Rippling
9.6
Subfascial Breast Augmentation Physician Assessment
Implant visibilityb
9.9
Range 1 -10 (1 being poor, 10 being excellent)
Muscular distortion with activityb
9.9
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Ptosis (pre-op vs post-op)b
9.8
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Double Bubble Deformityb
10
Implant deflation/deformationb
10
1. Breast Symmetry
2. Breast Shape
Range 1 -10 (1 severe, 10 none)
Implant malposition
3. Palpability
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
4. Rippling (visible or palpable)
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
5. Implant visibility
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
6. Muscular distortion with activity
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
7. Ptosis (Pre-op vs. Post-op)
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
8. Double Bubble Deformity
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
9. Implant Deflation/Deformation
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
10. Implant Malposition
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
11. Scarring
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10 |
Baker Level
|1|2|3|4|
Fig. 8 Physician assessment
because many patients were from out of state. Overall, 41
of the 61 patients returned to our office. The follow-up
period ranged from 2 to 24 months.
Results
Our patient questionnaire results are presented in Table 1 and
our physician assessment results in Table 2. Both assessments were very favorable, especially in terms of overall
patient satisfaction and muscular distortion with activity.
b
Scarringb
a
Range 1 (poor) to 10 (excellent)
b
Range 1 (severe) to 10 (none)
9.7
9.6
Figure 9 shows a 28-year-old woman preoperatively and
then 10 months after subfascial transaxillary endoscopic
augmentation using Mentor Moderate Plus Profile gel
(Mentor Corporate Offices, Santa Barbara, CA): 350 ml for
the left and 325 ml for the right. Figure 10 shows a 26year-old woman preoperatively and then 10 months after
450-ml right periareolar subfascial augmentation and a
400-ml left subfascial purse-string mastopexy using Mentor Moderate Plus gels.
Discussion
The subfascial breast augmentation procedure requires precise elevation of the pectoralis fascia superiorly and the
serratus and rectus fascia inferiorly based on the desired
pocket design. We use electrocautery for this meticulous,
delicate dissection requiring more attention to detail than
subglandular and submuscular dual-plane dissection.
Because of this, our average procedure time generally is 1 h
and 15 min compared with 45 min for dual-plane
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Fig. 9 A 28-year-old woman
10 months after subfascial
transaxillary endoscopic
augmentation using Mentor
MPP gel 350 ml for the left and
325 ml for the right. a
Preoperative series. b
Postoperative series
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Aesth Plast Surg
Fig. 10 A 26-year-old woman
10 months after 450-ml right
periareolar subfascial
augmentation and 400-ml left
subfascial purse-string
mastopexy using Mentor MPP
gels. a Preoperative series. b
Postoperative series
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Aesth Plast Surg
submuscular and subglandular implant placement. We
believe this additional time is well spent because of the
extremely high level of patient satisfaction and the high
predictability of the procedure with a very low revision rate.
At completion of the procedure, the visible result is what
will exist with final healing. No waiting period for the
implant to ‘‘settle down’’ into the pocket is necessary as
with many submuscular breast implant placements. The
somewhat unpredictable muscle descent holds the implant
high, which often necessitates breast bandeaus strips, vigorous massage, or other means (lowering capsulotomy) to
achieve the desired implant position.
The patient feedback on this subfascial breast augmentation series was highly positive, and the overall satisfaction
was very high. The patients were especially pleased with
their appearance and shape, the softness of the implant, and
the lack of implant palpability or visibility. They reported
little discomfort with the procedure, and all were pleased at
the lack of implant animation with arm movement (Fig. 11).
Fig. 11 A 28-year-old woman 7 months after bilateral subfascial
augmentation with inframammary incision using 371 ml of Inamed
style 15 gels. Virtually no animation occurs with muscular contraction. a Muscles relaxed. b Muscles flexed
123
Our physician assessment showed similar favorable
results. Overall, we found a uniformly pleasing breast
shape and symmetry, minimal rippling, and no muscular
distortion with activity. No ‘‘bottoming out’’ or recurrent
ptosis was observed. Capsular contracture ratings were
noted, and all patients were Baker class 1.
Proper patient selection during the preoperative assessment is paramount for achieving good results with subfascial
breast augmentation. A pinch test result of 2 cm or more
ensures proper upper pole coverage and prevents rippling,
palpability, and implant visibility that might otherwise be
seen. For patients with less upper pole coverage, the dualplane submuscular technique is recommended.
One may question why a thin fascial coverage provides
noticeable benefit compared with subglandular augmentation. However, this thin additional layer is but one benefit
of this procedure.
For a full understanding of the advantages offered by
subfascial placement, a discussion of anatomy is in order.
The breast is composed of an organized network of connective tissue comprising superficial and deep layers of
connective tissue running parallel to the skin and the pectoralis major muscle, respectively. Perpendicular fibers,
known as Cooper’s ligaments, join these layers (Fig. 12).
When the pocket plane is dissected for subglandular breast
augmentation, the fibers connecting the deep layer of the
Fig. 12 Fascial anatomy of the breast. Courtesy of Margie Aitken,
MD
Aesth Plast Surg
Table 3 Advantages
augmentation
and
disadvantages
of
subfascial
breast
Advantages
Disadvantages
Natural shape
Longer procedure
Less painful than
submuscular/dual-plane
More difficult dissection
Increased lower pole coverage
Less upper pole coverage
than with dual-plane
No muscular distortion
with arm movement
Highly predictable results
superficial fascia and the superficial layer of the deep pectoralis muscle fascia are divided. Disruption of these connections has been considered the cause for the early recurrent
ptosis and ‘‘bottoming out’’ seen with subglandular breast
augmentation [11]. When performed properly, implant
placement in the subfascial pocket preserves these important
attachments, lessening the possibility of subsequent breast
ptosis and maintaining better implant positioning.
We also have observed that the subfascial pocket plane
provides more lower pole coverage than either subglandular
or dual-plane submuscular placement. With the dual-plane
technique, the lower origins of the pectoralis major muscle
and fascia are released until subcutaneous fat is visualized,
leaving only fat and skin to overlie the lower pole. Similarly,
in addition to dividing Cooper’s Ligaments, the subglandular technique also places the lower pole of the implant under
a thin covering of skin and subcutaneous fat. This results in
less eventual chance for palpability, visibility, and implant
‘‘bottoming out’’ along the lower pole when the subfascial
technique is used. With subfascial breast augmentation, the
enhanced coverage of the lower pole comprises the continuous layer of fascia (pectoralis, serratus, rectus), the entire
thickness of the subcutaneous fat, and the skin.
We agree with previous reports describing the average
pectoralis fascia thickness measurement as approximately
1 mm [6]. However, the fascia is a strong, distinct layer
that can be visualized easily on intraoperative photos. This
layer has a significant strength that becomes apparent
during intraoperative manipulation, and when approximated, this layer provides continuous fascial coverage over
an implant. Table 3 compares the advantages and disadvantages of subfascial breast augmentation.
Conclusions
Subfascial breast augmentation provides for the naturally
pleasing shape of subglandular augmentation while preserving the fascial framework to lessen postoperative
breast implant ptosis. This procedure provides significant
additional implant coverage to prevent palpability and
visibility without the added postoperative pain and disturbing implant animation experienced with submuscular
placement. The discomfort associated with this procedure
is minimal, and the recovery is very rapid. Overall patient
and physician satisfaction is extremely high. For these
reasons, subfascial implant placement has become our
preferred technique for breast augmentation.
Acknowledgment We thank Dr. Margie Aitken for providing an
artistic depiction of the fascial system of the breast.
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