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SUBFASCIAL BREAST AUGMENTATION

New Breast Augmentation
Anatomic prosthesis placement at subfascial plane, with axillary approach assisted by endoscopy.

This technique has been introduced by Dr. Graff and we have been pioneers around the world applying the technique, placement of anatomic implants at subfascial level assisted by endoscopy has become a revolutionary and successful technique, providing excellent aesthetic outcomes in breast surgery.


This technique is especially indicated in:
• women presenting small breasts (breast hipoplasia)
• women after one or more breast feeding episodes presenting breast size reduction associated to skin flaccidity but without ptosis (areola is located at the level or above the mammary fold).

New: subfascial plane
From the anatomic point of view, pectoralis muscle is covered by a fascia, made of a sort of fibrous sheet separating it from surrounding tissues. In this technique, the pectoralis muscle fascia is dissected off the underlying muscle placing the prosthesis in this plane, under the pectoralis fascia. Classically, breast implants were placed under the muscle (submuscular placement) or overlying the muscle just behind the gland (subglandular placement). Applying this new technique we gather the advantages of both classical techniques avoiding drawbacks:

• Takes over subglandular placement since in this plane, prosthesis and gland weight is borne by skin solely (breast retaining ligaments anchoring to the fascia are severed), developing breast ptosis as time goes by. However, with subfascial placement, the fascia plays a role supporting the prosthesis, eliminating tendency to develop ptosis, and at the same time upper pole fullness of the breast is achieved like subglandular implants do.

Surgical procedure
Step by step

• Initially, a 4 cm incision is made coinciding with a natural fold in the axilla, going from anterior axillary line but never crossing beyond the anterior edge of the pectoralis major muscle, hiding any scar.
- After skin incision is made, superficial fascia of pectoralis major muscle is identified and exposed, which is scored along a parallel line to muscle fibers over the edge of the muscle.

• Then, the undersurface of the pectoralis muscle fascia overlying muscle fibers is undermined assisted by lighted retractor connected to the endoscopic system designed by us (Serra-Renom Endoscopic Swivel Retractor System). Once the most distal edge of the muscle is reached, the fascia is incised horizontally along the 6th rib and subcutaneous dissection is performed to the desired final location of the new mammary fold.

• After performing the pocket for the prosthesis, a sizer implant is placed filled in with saline, providing useful information about the final volume needed while comparing one side to the other seeking for symmetry. Once the final volume is assessed, the sizer is removed and any bleeding point is checked out with the endoscope. In that moment, reference points within the final prosthesis are scored in the skin applying specular reflection or a pattern.

• Anatomic implant is placed and its correct position is checked out looking for reference points assisted by endoscope.

• Suction drain is placed and axillar incision is closed. We consider that carefully placed bandage kept in for a week to maintain the implant in the correct position avoiding rotation, is essential. During the following month, the patient must sleep strictly in a supine position wearing a brassier to keep the implants in position. The suction drain is removed after 24 hours. We have performed this technique in 165 patients with very satisfying postoperative period without any discomfort. No cases of implant rotation or displacement have been reported. Anatomic implants provide adequate fullness of breast upper pole. Axillary scar evolve very satisfactorily with no hypertrophic scarring.

 

Implant type and approach
For breast augmentation we use anatomic cohesive gel “Soft touch” implants instead of classic round shape ones, offering a wide variety of options in terms of shape, height, width and projection, achieving fullness of the upper poles. In this way, we can match the most suitable implant for each patient. We prefer axillary approach because the scar can be hidden completely and the mammary gland is not disturbed.

The ideal candidate to undergo this technique is a woman with:

• Breast hypoplasia
• Empty breast after one or more lactation
• Skin flaccidity without ptosis

Pinching test is performed to assess the thickness of skin-subcutaneous layer, since subfascial implant placement is determined by the presence of enough glandular and fatty tissue to provide adequate implant covering.

Placing anatomic implants at the subfascial plane:

• Breast fullness is achieved and particularly of the upper pole, since the implant is located behind the gland.

• Recovery during early postoperative period is better and less painful.

• Ptosis incidence is not increased since the fascia bears the weight of the prosthesis since fibrous connections between the deep layer of the superficial fascia and pectoralis major fascia are preserved.

In conclusion, we believe that anatomic implants placement through axillary approach in a subfascial plane combines the advantages of subglandular and submuscular placement, avoiding their drawbacks. Since the prosthesis is anatomic cohesive gel “Soft touch” (softer) implant, its placement from the axilla is easier. Endoscopic assistance facilitates the procedure providing excellent outcomes.

 
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