Subfascial Breast Augmentation: A Comprehensive Experience

Transcription

1 Aesth Plast Surg (2010) 34: DOI /s ORIGINAL ARTICLE Subfascial Breast Augmentation: A Comprehensive Experience Joseph P. Hunstad L. Shayne Webb Received: 2 July 2009 / Accepted: 31 July 2009 / Published online: 29 January 2010 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 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, Statesville Road, Huntersville, NC 28078, USA jphunstad@gmail.com; jph1@hunstadcenter.com L. S. Webb Nirvana Plastic Surgery, th 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 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

2 366 Aesth Plast Surg (2010) 34: 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 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. 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-CARE Ò 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

3 Aesth Plast Surg (2010) 34: 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

4 368 Aesth Plast Surg (2010) 34: 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. 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

5 Aesth Plast Surg (2010) 34: Patient Questionnaire for Subfascial Breast Augmentation We are conducting a study in regard to patient satisfaction. Please take a few minutes to complete the questionnaire. How do you rate the following factors? Range 1-10 (1 being poor, 10 being excellent) Poor Good Excellent 1. Overall satisfaction Overall appearance & shape Pain with procedure Symmetry Scarring Softness Nipple sensitivity Range 1-10 (1 being severe, 10 being none) Severe None 8. Implant animation jumping Rippling Palpability Discomfort Fig. 7 Patient questionnaire Subfascial Breast Augmentation Physician Assessment Range 1-10 (1 being poor, 10 being excellent) 1. Breast Symmetry Breast Shape Range 1-10 (1 severe, 10 none) 3. Palpability Rippling (visible or palpable) Implant visibility Muscular distortion with activity Ptosis (Pre-op vs. Post-op) Double Bubble Deformity Implant Deflation/Deformation Implant Malposition Scarring Baker Level 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. Table 1 Patient questionnaire results averaged for all the patients Overall satisfaction a 9.3 Overall appearance & shape a 9.3 Pain with procedure a 8.7 Symmetry a 9.1 Scarring a 9.0 Softness a 9.9 Nipple sensitivity a 8.8 Implant animation jumping b 9.9 Rippling b 9.5 Palpability b 9.5 Discomfort b 9.8 a Range 1 (poor) to 10 (excellent) b Range 1 (severe) to 10 (none) Table 2 Physician assessment results averaged for all the patients Breast symmetry a 9.5 Breast shape a 9.5 Palpability b 9.5 Rippling b 9.6 Implant visibility b 9.9 Muscular distortion with activity b 9.9 Ptosis (pre-op vs post-op) b 9.8 Double Bubble Deformity b 10 Implant deflation/deformation b 10 Implant malposition b 9.7 Scarring b 9.6 a Range 1 (poor) to 10 (excellent) b Range 1 (severe) to 10 (none) 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 26- year-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

6 370 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 Aesth Plast Surg (2010) 34:

7 Aesth Plast Surg (2010) 34: 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

8 372 Aesth Plast Surg (2010) 34: 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). 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. 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 Fig. 12 Fascial anatomy of the breast. Courtesy of Margie Aitken, MD

9 Aesth Plast Surg (2010) 34: Table 3 Advantages and disadvantages of subfascial breast augmentation Advantages Natural shape Less painful than submuscular/dual-plane Increased lower pole coverage 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 Disadvantages Longer procedure More difficult dissection Less upper pole coverage than with dual-plane 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. References 1. Cronin TD, Gerow FJ (1964) Augmentation mammaplasty: a new natural feel prosthesis. In: Transactions of the third international congress of plastic surgery. Excerpta Medica Foundation, Amsterdam, pp Dempsey WC, Latham WD (1968) Subpectoral implants in augmentation mammaplasty: preliminary report. Plast Reconstr Surg 42: Goes JCS, Landecker A (2003) Optimizing outcomes in breast augmentation: seven years of experience with the subfascial plane. Aesth Plast Surg 27: Graf RM, Bernardes A, Auersvald A, Costa Damasio RC (2000) Subfascial endoscopic transaxillary augmentation mammaplasty. Aesth Plast Surg 24: Graf RM et al (2003) Subfascial implant: a new procedure. Plast Reconstr Surg 111: Jinde L et al (2006) Anatomy and clinical significance of pectoral fascia. Plast Reconstr Surg 118: Mladick RA (1993) No-touch submuscular saline breast augmentation technique. Aesth Plast Surg 17: Munhoz AM et al (2006) Subfascial transaxillary breast augmentation without endoscopic assistance: technical aspects and outcome. Aesth Plast Surg 30: Puckett CL, Croll GH, Reichel CA, Concannon MJ (1987) A critical look at capsule contracture in subglandular versus subpectoral mammary augmentation. Aesth Plast Surg 11: Ramirez OM, Heller L, Tebbetts JB (2002) Dual-plane breast augmentation: avoiding pectoralis major displacement. Plast Reconstr Surg 110: Serra-Renom JM, Garrido MF, Yoon T (2005) Augmentation mammaplasty with anatomic soft, cohesive silicone implant using the transaxillary approach at a subfascial level with endoscopic assistance. Plast Reconstr Surg 116: Siclovan HR, Jomah JA (2008) Advantages and outcomes in subfascial breast augmentation: a two-year review of experience. Aesth Plast Surg 32: Spear SL, Schwartz J, Dayan JH, Clemens MW (2009) Outcome assessment of breast distortion following submuscular breast augmentation. Aesth Plast Surg 33: Stoff-Khalili MA, Scholze R, Morgan WR, Metcalf JD (2004) Subfascial periareolar augmentation mammaplasty. Plast Reconstr Surg 114: Tebbetts JB (2006) Dual-plane breast augmentation: optimizing implant soft tissue relationships in a wide range of breast types. Plast Reconstr Surg 118(7 Suppl):81S 98S 16. Vazquez B, Given KS, Houston GC (1987) Breast augmentation: a review of subglandular and submuscular implantation. Aesth Plast Surg 11: