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Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 4-13

Experience on subfascial mammary augmentation and influence of incisions on technique

Department of Plastic, Reconstructive and Aesthetic Surgery, Abant Izzet Baysal University, Gölköy, Bolu, Turkey

Date of Submission10-Jan-2020
Date of Acceptance16-Jan-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Metin Gorgu
Department of Plastic, Reconstructive and Aesthetic Surgery, Abant Izzet Baysal University, Gölköy, Bolu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_93_19

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Introduction: Mammary augmentation is among the most popular types of cosmetic procedures and mammary prosthesis the most commonly accepted technique. A mammary prosthesis can be placed on transaxillary, periareolar, submammary incisions in subglandular, subpectoral, subfascial planes or in a combination of planes. Given the potential interaction between the prosthesis and the surrounding tissues, the plane in which the prosthesis is implanted has an important role among the factors affecting this interaction. The plastic surgeon decides on the incision and plane to be used by assessing the advantages and disadvantages. Materials and Methods: Prostheses were implanted in the subfascial plane in 47 patients who underwent augmentation mammaplasty. Round Moderate Plus or High Profile Cohesive II™ Gel implants were used. Device volumes ranged from 275 to 600 cc. Of the 47 procedures, 23 were performed over an axillary incision, 20 over an inframammary incision, and 4 over a periareolar incision. Endoscopic-assisted dissection was performed in all of the 23 cases in which transaxillary incision was used. Results: All 47 patients who underwent subfascial prosthesis implantation were followed up for a mean of 5 years (range: 2–7 years). Long-term results were satisfactory with few complications. The overall patient satisfaction rate was 89.3%, and none of the patients required an implant removal or change. None of the patients complained of severe pain, regardless of the type of incision, and resumed their daily activities on postoperative day 2. Conclusion: The subfascial augmentation technique provides good and long-term results. It requires longer operating times and is a more difficult technique compared to other planes. As the choice of incision does not largely affect the overall result, the position of the scar depends on the patient's preference, the properties of the implant, and the experience of the surgeon. The endoscopic assistance should be preferred when using the transaxillary approach.

Keywords: Augmentation mammoplasty, augmentation mammoplasty, endoscopy, subfascial, transaxillary incision

How to cite this article:
Gokkaya A, Gorgu M. Experience on subfascial mammary augmentation and influence of incisions on technique. Turk J Plast Surg 2021;29:4-13

How to cite this URL:
Gokkaya A, Gorgu M. Experience on subfascial mammary augmentation and influence of incisions on technique. Turk J Plast Surg [serial online] 2021 [cited 2022 Dec 7];29:4-13. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/4/305913

  Introduction Top

The female breast is not only a symbol of motherhood but is also considered a symbol of female beauty in some cultures. Therefore, over the years, female breasts have been manipulated and modified by aesthetic surgeons. As a result of cultural changes, technological advancements, development of modern implants as well as new surgical techniques, augmentation mammaplasty has become one of the major procedures performed by aesthetic surgery.

A mammary prosthesis can be placed on transaxillary, periareolar, submammary incisions in subglandular, subpectoral, subfascial planes or in a combination of planes. The subfascial plane described by Graf offers the advantages of the two other planes yet has none of their disadvantages.[1],[2],[3],[4] The plastic surgeon evaluates the plane of the implant, the characteristics of the dissection, and the properties of the prosthesis to determine the position and the length of the incision.[5] The choice of incision should allow for easy access (ensuring accurate dissection and hemostasis of the pocket), nondisruption of the breast's parenchyma, and a less conspicuous scar.[6] The choice of incision can affect the level of trauma to the soft tissue, the exposure of the implant to the endogenous bacteria in the mammary tissue, the visibility and the command of the surgeon, any potential damage to the neurovascular structures, and postoperative morbidity.

The mammary glands are contained between two sheets of the superficial fascia, and below the deep sheet of the superficial fascia is the muscular aponeurotic fascia. Between these two fascia layers lay the retromammary space where subglandular prosthesis is inserted. Some lobes of the mammary gland can extend into this space. This area also accommodates a number of lymphatic ducts that terminate in the Level III nodes. Furthermore, on this plane are the Cooper's ligaments that extend from the dermis to the musculo-aponeurotic fascia passing through the deep layer of the superficial fascia. The function of these structures is to attach the breast to the thorax. Subglandular prostheses, affecting the structures in this region, partially damage the suspension system of the breast. The pectoral fascia is a thin layer attached to the sternum and the clavicle, covering the pectoralis muscle; it is located on the pectoral muscle on the upper two-third of the breast and extends laterally to the back fascia (musculus serratus anterior) and downward with the abdominal wall fascia (musculus rectus fascia).[1],[6],[7],[8] There are many fine fibrous bundles between the upper pectoral fascia and the superficial fascia of the breast.[1],[6],[8] At the level of the fourth intercostal space, a dense horizontal septum connects the pectoral fascia and the nipple. Extending medially and laterally the septum joins with the medial and the lateral ligaments of the breast.[1],[6],[7],[8] There is a dense connective tissue along the inframammary sulcus that connects the skin and inframammary crease. The thickness of the pectoral fascia varies from 0.2 to 1.14 mm; while the measurements show individual and racial differences, the fascia is always thicker in the superior and thinner in the inferior. Because tearing in the fascia occurs at the inferior edge, the transaxillary approach is more advantageous for subfascial placement.[1],[7],[9]

The plane of the prosthesis and the site of the incision are the decision of the plastic surgeon even though the patient's preferences are taken into account. Assessing the advantages and disadvantages of the incision types and dissection planes, the plastic surgeon decides on the mode of the procedure and the type of the implant taking into account a number of factors including the skin structure, the muscle characteristics, and activity behavior of the patient. The decision is also informed by the plastic surgeon's level of experience and the availability of the necessary equipment. This study presents our subfascial augmentation mammaplasty case series and the details of the endoscopic-assisted augmentation mammaplasty performed using transaxillary incision and the subfascial plane together with our clinical experience.

  Materials and Methods Top

Forty-seven mammary augmentation patients whose implants were placed in the subfascial plane were analyzed. The age of the patients ranged from 18 to 44 years. Round Moderate Plus or High Profile Cohesive II™ Gel implants were used. Device volumes ranged from 275 to 600 cc. The procedures were performed over an axillary incision in 23 cases, an inframammary incision in 20 cases, and a periareolar incision in four cases. Implants were chosen according to the limitations of the patients' body measurements and in line with their expectations. Pinch test results were more than 2 cm in 39 patients and <2 cm in eight patients. Endoscopic-assisted dissection was performed in all of the 23 cases in which transaxillary incision was used. Patients were asked to evaluate the results expressing their level of satisfaction as good, average, and poor [Table 1]. Capsular contracture, scar visibility, level of malposition, axillary banding, rippling, and complications were evaluated by the surgeon [Table 1].
Table 1: Satisfaction rate and complications of subfascial plane for different incisions

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Surgical technique for transaxillary subfascial augmentation mammaplasty

Patients are operated on under general anesthesia in supine position with arms abducted to 90 degrees and the back of the operating table lifted at 15 degrees. To reduce bleeding, 50 cc adrenaline solution (1:100,000) is infiltrated into the site of the dissection. After incision and dissection of skin and subcutaneous tissues, the dissection is carefully advanced up to the lateral edge of the pectoral muscle over the subcutaneous plane without deepening or approaching the underlying axillary content [Figure 1] and [Figure 2]. When passing across the axilla to the arm, it is important to observe that the dissection is made over the superior of the axillary fat pad in order to preserve (most damage occurs in this region) the intercostobrachial nerve (ICBN) and the axillary lymph nodes. To pass to the subfascial plane at the edge of the muscle, the fascia is incised so that it remains parallel to the muscle fibers [Figure 1] and [Figure 2]. Dissection is performed first to the superomedial, then over the midline, to the nipple, the inferomedial, and the lateral. At the nipple level, the nipple should be pulled vertically to open the dissection space. Dissection is done bluntly and sharply with long Metzenbaum scissors parallel to the muscle fibers. Septal fibrous attachments that advance to the pectoral fascia through the muscle fibers are cauterized and cut under an endoscope [Figure 3]. All vessels seen during dissection are cauterized, and even though there is no consensus in the literature about the bleeding of subfascial dissection, according to the clinical experience of the author, this plane bleeds more than the others and requires meticulous hemostasis. There are more fibrous strips, and there is more vascularization in the area of the nipple projection. To maintain the integrity of the fascia, the dissection is performed in favor of the fascia rather than the muscle. Since the fascia thins over the inferior border, it may be necessary to preserve part of the muscle fibers on the fascia to maintain its integrity. Several arteries found in the vicinity of the rectal fascia on the inferior edge are cauterized. The attachments from the fascia to the skin at the fold level are sectioned to avoid future deformities in the lower breast. The lateral part of the dissection is more difficult to approach, visibility and dissection with regular instruments are difficult, and there are several smaller vascular structures at the lateral edge that need to be cauterized. During lateral dissection, the lateral border should be limited to avoid injury to the lateral cutaneous nerves and the lymphatic channels. When large implants are planned or in patients with a wide sternum, the dissection can be advanced to the medial and across the lateral edge of the sternum, in which case perforator vessels are encountered and must be carefully cauterized. At the end of the dissection, a subfascial pouch is created including the pectoral fascia, partially the serratus, and where available, partially the rectus fascia; if the skin is thick, the rectus fascia may not be dissected. It is sufficient to repair the fascia with 3 pieces of 3-0 absorbable suture once the prosthesis is in place [Figure 4]. Here, a few sutures will be sufficient, since in the transaxillary subfascial approach, there is no muscle force to push the prosthesis toward the incision, and the suture line is away from the edge of the prosthesis. Before suturing the skin, a 2–3 mm thick strip is excised of the skin tissue at the damaged anterior border of the incision [Figure 4]. In our experience, oozing is more common in the subfascial plane compared to other planes, and the drain pulls out the air initially remaining in the pouch and then ensures that the pouch is free of blood. Pressure dressing is applied to complete the procedure; the bandage may be applied firmly as there is no possibility of exerting force on the sutures. On the average, drainage tubes are kept for three days after the operation.
Figure 1: Access to pectoral fascia and initial dissection of transaxillary subfascial approach

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Figure 2: Operation steps of transaxillary endoscopic-assisted mammary augmentation

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Figure 3: Endoscopic view of transaxillary subfascial dissection

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Figure 4: Pectoral fascia sutures and skin trimming

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  Results Top

All 47 patients who underwent subfascial prosthesis implantation were followed up for a mean of 5 years (range: 2–7 years). Pleasing long-term results were obtained with the subfascial breast augmentation technique regardless of the incision type [Table 1]. A few complications were encountered. Grade II capsular contractures were observed in two of the 47 patients in whom the subfascial plane was used, and no interventions were made. In all except one of the patients, a hidden scar was achieved without compromising the aesthetic result with transaxillary incision. No hematoma or infection was encountered, and there was no need for re-surgery to correct implant malposition. Rippling occurred in five patients at the upper sternal border of the implant (pinch test was <2 cm), and in two of these five patients, the edges of implant were also visible, and two patients had acceptable malposition and asymmetry. The overall patient satisfaction rate was 89.3% for the subfascial, and none of the patients required an implant removal or change. None of the patients complained of severe pain, regardless of the type of incision, and resumed their daily activities on postoperative day 2 with the help of 2 g paracetamol daily. Nerve damage was not observed. Six patients had transient sensory changes in the nipple area where this occurred as numbness in three and as hyperesthesia in three patients. Axillary cording occurred in one patient on whom transaxillary incision was performed and healed after a 3-month treatment, and Mondor's syndrome was seen in one patient. Complications such as hematoma, permanent hypertrophic scar, or infection were not encountered.

  Discussion Top

The characteristics, advantages, and disadvantages of the planes where the implants can be placed and where these planes are indicated and contraindicated have been addressed in detail in many reports [Table 2].[4],[6],[10],[11],[12],[13],[14],[15] While the major planes are the subglandular, subpectoral, and the subfascial, combined techniques including triple-plane, dual-plane, dual-plane subfascial, retromammary adipofascial flaps, composite breast augmentation with fat graft, and implant, segmental muscle flaps are also used.[2],[3],[4],[15],[16]
Table 2: Comparison of planes implant placed[4],[6],[11],[12],[15],[24],[25],[26]

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The subglandular plane provides a good-looking shape and enables an easy surgery, convenient dissection plane, as well as rapid postoperative recovery and is a technique that is presently used, especially in patients with sufficiently thick breast tissue. In the subglandular plane, visibility of the implant's margins and rippling of the implant (especially in thin patients) are possible because of inadequate upper pole coverage, and the risk of capsular contracture is higher.[6],[17]

The subpectoral plane eliminates the issue at the upper pole as well as that of rippling; edges of the implant do not show, and thinness of the patient's skin does not pose a problem. Another significant advantage of the subpectoral plane is that capsular contracture is less common.

The disadvantage of the subpectoral plane is associated with the strength and the movement of the muscle. Contraction of the pectoral muscle may cause distortion and animation of the breast, flattening of the implant and the breast may demonstrate deformity similar to a tear trough deformity along the lower lateral edge of the pectoralis major muscle.[6],[17] Modifications, such as total submuscular placement, muscle split technique, and dual-plane technique, have been introduced to minimize the issues on the subpectoral plane. Moreover, postoperative recovery time after subpectoral placement is longer, and it will take longer for the breast to take its final shape.[6],[17]

The subfascial plane offers the advantages of the two techniques without their disadvantages. Breast shape is satisfactory, upper pole problems are eliminated, edges of the implants are not visible, aesthetic results are as good as those of the subglandular plane, there are less edema and seroma (less lymphatic system) and less ptosis (Cooper's ligaments are preserved), inferior ptosis is prevented (fascia support is helpful), the integrity of pectoral muscle is preserved, there are not any muscle contraction problems (no animation or breast disfigurement), recovery is faster compared to submuscular placement, patients experience less pain (because the pectoral muscle is not detached from any of its insertions and there isn't any mass under the muscle ), arm movement does not cause pain, the implant position is under the gland, in other words on its natural plane, patients resume their activities sooner and can resume vigorous physical exercise immediately after the stitches are removed,  Staphylococcus epidermidis Scientific Name Search amination is unlikely.[5],[6],[16],[17] While it is important for the upper part of the implant to remain covered in fascia to reduce the risk of rippling, problems such as visible implant edges and visible rippling may occur when the subfascial plane is used in patients with a pinch test <2 cm.[5],[6],[17],[18] The thickened fascia of the upper pole provides support and elasticity and excellent coverage over the implant.[5] At the same time, keeping the upper and central parts covered with fascia prevents the implant from contacting with the more reactive adipose tissue under the gland, thus preventing an inflammation that may result in capsular contracture.[18] Subfascial augmentation, rather than padding the pectoral fascia, helps to maintain the implant in position by keeping it from slipping.[8] The lower pole of the breast above the inframammary fold lacks sufficient soft-tissue coverage over the implant.[19] Han et al.[19] described a retromammary adipofascial flap, which resembles a half subfascial plane dissection, to support the coverage of the implant at the inframammary level in subpectoral plane implants. In general, implant coverage is not totally subfascial, and the lower pole of the implant is under the gland.[4],[8],[17],[18] In the series of 27 cases, Aygit et al.[13] dissected the fasciae of the pectoralis, rectus, serratus, and external oblique muscles as a whole to maintain the integrity of the fascia of the ouch that they created for the implant using the transaxillary totally subfascial breast augmentation technique and achieved near-perfect results.[13] Tijerina et al.,[5] in their large series of 1,000 patients, placed soft gel cohesive textured implants of maximum 600 cc (mean 310 cc) through an inframammary incision in 95% and periareolar incision in 5% of their patients with a subfascial approach. The authors report that the dissection provided good hemostasis and did not necessitate drainage. Kerfant et al.[20] performed composite subfascial augmentation by supporting subfascial implants with fat grafts to reduce the visibility of the prosthetic edges. While achieving the desired breast volume with a suitably sized subfascial implant, they also achieved natural-looking results, especially in thin patients, with fat injections to the cleavage and the presternal areas.[20]

The authors report that, in their experience, the location of the incision had no significant impact on the results of the subfascial technique [Table 1], and therefore, the choice of the incision would depend on the patient's request, the prosthesis to be used, the patient's physical characteristics, and the surgeon's experience. The location of the incision is especially important regarding scar visibility; however, the advantages and disadvantages of each incision should be evaluated for each patient and each surgeon. The inframammary incision is technically the easiest and the most preferred approach.

Subfascial implant placement through inframammary incision has the advantages of easy technique, direct observation, comfortable and open dissection, and effective hemostasis [Figure 5] and [Figure 6]. The technique does not cause damage in breast parenchyma and is suitable for placing any type of prosthesis, and the scar remains in the inframammary fold. The incision can be lengthened as needed. One of its disadvantages is the visible scarring around the breast area, which is a major issue for some patients. Another disadvantage is that the layers must be firmly sutured since the prosthesis creates direct tension on the suture line and will be exposed if the stitches open up.
Figure 5: View of subfascial dissection plane with three different incisions: transaxillary, periareolar, and inframammary

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Figure 6: Inframammary subfascial augmentation mammaplasty

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The periareolar incision is the best option for hiding the incision scar from view, and once healed, the scar will be barely visible. The areola has good exposure if not too small. The limited approach in smaller areolas and the restrictions in terms of the size and type of implant, and the varied levels of damage that the surgery inflicts on the breast tissue, as well as changes in sensation and loss of sensation in the areola are its major disadvantages [Figure 5] and [Figure 7].
Figure 7: Periareolar subfascial augmentation mammaplasty

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In the transaxillary approach, the incision is far from the breast, thus visibility of postoperative scars are reduced and safety of the incision suture is high, also prosthesis will not be exposed even if there is suture separation [4],[5],[10],[11],[12],[16],[17],[21] [Figure 5] and [Figure 7]. It allows for the better placement of the silicone prosthesis at the inferior and helps for improved inframammary crease management.[12] Technical challenges are its disadvantages; in the absence of an endoscope, dissection is performed blindly at the inferior, and the inferior halves of the medial and the lateral, adequate hemostasis may not be achieved. Whereas the ICBN is prone to risks in transaxillary approach, in subfascial dissection, injury to the ICBN is less likely than in submuscular dissection because the dissection remains more superficial.[5],[17] Transaxillary incision used for transaxillary breast augmentation with gel-filled implants is traumatic to the armpit and the breast tissue because of the pushing force and the effort needed to introduce the implant in the pocket.[22] In the transaxillary approach, In the transaxillary approach, the support of the endoscope is critical on the subfascial plane dissection whereas dissection in subpectoral or subglandular planes without endoscope is possible, the support of the endoscope is critical, especially on the subfascial plane. The distance to the inferomedial point, which is the farthest from the axilla, is quite long. Technically, the transaxillary subfascial approach is more difficult than the transaxillary subpectoral and subglandular approaches.[16] A clean endoscopic view with long retractors, scissors, and cautery can help to overcome these difficulties[16] [Figure 8]. While some believe that an endoscope is not routinely required in standard subfascial augmentation procedures, in our practice, we always performed transaxillary incisions with the help of an endoscope.[17],[21],[23],[24]
Figure 8: Endoscopic set for transaxillary endoscopic-assisted mammary augmentation

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The significance of transaxillary incisions is the absence of a visible scar in some areas around the breast [Figure 9], [Figure 10], [Figure 11], [Figure 12]. Today, however, we see that the location of the scar is less important for patients, while the aesthetic outcome and reduced risk of complications come to the fore. A significant advantage of the transaxillary approach is the absence of an incision or suture, hence the possibility of dehiscence, in the area where the implant is placed and especially in the inframammary area under the weight of the prosthesis. It is especially important when placing large-size implants in the inframammary area in patients with thin skin. In addition, tight bandages can be applied without problem to reduce the risk of hematoma since the pressure exerted by the bandages will remain away from the incision line. Slightly hypertrophic scars, widened scars, will require secondary correction as axillary scarring will be visible when lifting the arms, especially at the beach, when wearing a swimwear. Niechajev[21] reported that while 30% of the patients in whom he used the inframammary approach found the scarring outcome “very good,” more than 90% of the patients in whom he used the axillary approach found the outcome highly satisfactory. The satisfaction rate was also high among our patients. Transaxillary breast augmentation was indicated for patients with breasts of small or moderate volume without ptosis, patients who wanted no breast scars, and patients who had a poorly defined inframammary fold.[23] To avoid double folds and a double-bubble appearance, the inframammary fold should not be lowered, especially in ptotic breasts.[17]
Figure 9: Case presentation 1: Transaxillary, subfascial, endoscopic-assisted mammary augmentation

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Figure 10: Case presentation 2: Transaxillary endoscopic-assisted mammary augmentation

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Figure 11: Case presentation 3: Transaxillary, subfascial, endoscopic-assisted mammary augmentation

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Figure 12: Case presentation 4: Transaxillary, subfascial, endoscopic-assisted mammary augmentation

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In our clinical practice, all transaxillary approaches were performed with the help of an endoscope. The endoscopic light provides a detailed view for dissection and enables meticulous hemostasis. Such an approach requires using long retractors, long scissors, and especially long endoscopic cautery [Figure 8]. Otherwise, excessive pressure will be applied to the edges of the axillary incision. Moreover, it will be difficult to reach the inferomedial, especially in patients with large thoracic dimensions. In our practice, we use a 30-degree angle, 5 mm, 24 cm telescope (Karl Storz, Tuttlingen, Germany) [Figure 8]. Using an endoscope helps the surgeon to dissect the pocket more precisely, to obtain effective hemostasis, and to better control the inframammary fold and provides a more comfortable recovery period for the patient.[11],[12],[21] Momeni et al. having performed transaxillary subpectoral dissections by finger and with the help of a dissector report that in endoscopic follow-up examinations, they identified that additional dissection was needed in more than 90% of the cases because of the presence of muscular bands, especially at the sternocostal origin of the pectoralis major muscle.[10] Momeni et al. report that they did not encounter in their series any of the complications that could occur after disrupting the muscular attachments of the pectoralis muscle and that would incorporate potentially harmful effects such as implant visibility, rippling, and an increased rate of hematoma formation.[10] Jinde et al. concluded that the integrity of pectoral fasciae is usually preserved in transaxillary subfascial breast augmentation even without endoscopic assistance, and when there is distortion at the lower portion of the pectoral fascia, it did not interfere with the aesthetic outcome or postoperative recovery.[24] Benito-Ruiz et al. have performed breast augmentations using cohesive gel-filled form-stable implants with the transaxillary approach and the periareolar approach and reported that the transaxillary approach was safer with lower complication and reoperation rates.[25] The authors found the transaxillary approach safer and more beneficial in the subfascial plane than the submuscular plane.[25]

The transaxillary approach and sentinel lymph node

It is argued that because of the trauma to the axillary region, this approach may harm the sentinel lymph node (SLN) assessment in a surgery that may potentially be necessary in the future.[22],[23],[26],[27],[28],[29] Prado et al. in their study concluded that during the dissection, and especially when placing the implant in the breast pocket, the traction and counter traction could traumatize the lymph nodes of the armpit where the sentinel node is located.[22] Prado et al. reported that this problem would not occur with saline implants, whereas trauma to the sentinel node area of the armpit was possible with rigid gel-filled implants, especially in larger sizes.[22] Sado et al. used lymphoscintigraphy preoperatively and postoperatively in transaxillary augmentation mammaplasty patients and did not find a significant difference in finding the SLN or in its localization; while the difference was observed in the extra-axillary lymphatic chains of 15-22% of the patients, the authors did not encounter totally different and/or the absence of lymphatic drainage in any of their patients.[27] The authors concluded that temporary partial impairment could occur immediately after the operation in lymphatic drainage and could recover totally in the late postoperative period. The authors concluded that axillary lymphatic drainage would be preserved and would not be an obstacle in detecting the SLN.[27] Mottura et al. concluded that a careful dissection is needed to protect the lymphatic vessels and for sentinel node mapping without problems at the axillary soft-tissue triangle lateral and inferior to the pectoralis major muscle.[29] In transaxillary subfascial breast augmentation, dissection should continue on the high and anterior section of the subcutaneous plane up to the lateral of the pectoral muscle to minimize disruption to the lymphatics.[22],[23],[26],[27],[28],[29]

Properties of the prosthesis used in the transaxillary approach are important; placement of rigid, cohesive gel-filled prostheses is difficult, especially in larger sizes. In our practice, when using implants larger than 350 cc, we prefer softer prostheses or the inframammary approach in cases which we do not want to extend the incision. When anatomic implants or large silicone gel implants, especially cohesive gel-filled ones are used, the transaxillary approach has significant disadvantages over the breast incision techniques.[23] Momeni et al., however, do not agree that a short length of the incision would limit the implant size with intermediate volumes.[10] In our experience, it would be difficult to place implants larger than 350 cc, especially anatomic implants, without damaging the axillary incision and the axillary content. In transaxillary approaches using larger size implants, prostheses filled with more fluid gel (such as Cohesive I) that allow for an hourglass procedure or more slippery, nontextured prostheses should be considered. In our experience, the type of the implant is important, and it will be possible to insert the implant, regardless of the size, through a 3–4 cm incision with the hourglass procedure. The cohesiveness of the gel, the softness of the silicone outer shell of the implant, and whether it is textured or not are important. If the implant is large and filled with Cohesive II gel, it will be more difficult to insert through a small incision. In the transaxillary submuscular approach, the prosthesis can be placed more easily than the subfacial approach because of the more appropriate angle. In addition to its advantages in scarring, the transaxillary approach allows for subfascial dissection under direct observation and adequate placement of the inframammary crease.[12],[25] Munhoz et al. reported that the form-stable texture with a higher degree of cross-linking within the gels allowed anatomic cohesive gel implants to preserve their shape in all positions.[12] The authors reported that the transaxillary subfascial technique and form-stable anatomic implants could be considered in patients who do not have sufficient tissue thickness, have no or high inframammary fold, or necessitate more volume in the lower pole.[12] According to Munhoz et al., transaxillary subfascial augmentation is suitable in small or moderate size breasts and without ptosis.[23] Additional methods have been described in the literature to facilitate implant placement, such as drain placement to prevent air entrapment, filling the cavity with serum and using sterile gel to help sliding, and using Keller funnel.[21] Nevertheless, every plastic surgeon should define and develop their own practice.

In our study, the overall patient satisfaction was 89.3%. Patient satisfaction by incisions was 91.3% for transaxillary, 90% for inframammary, and 75% for periareolar [Figure 6], [Figure 7] and [Figure 9], [Figure 10], [Figure 11], [Figure 12]. In general, we analyzed our satisfaction rates in respect of the subfascial plane (89.3%) and could not comparatively analyze the distribution of satisfaction rates by incisions because of the differences in the number of cases. In terms of the number of cases in the series, while axillary and inframammary incision preferences are comparable in number, the periareolar approach is less. We observed two reasons that come forth as to why the periareolar incision, despite leaving a less visible scar, is less preferred than the other two incisions. Patients try to avoid interventions that could lead to sensory changes in the nipple or interventions in the breast tissue. As for the surgeon, technical challenges come forth; the short length of the incision (especially in smaller areolas) makes dissection and hemostasis difficult and prolongs operating time, and decreased fluidity of the prostheses (cohesive gels and anatomic prostheses) makes it difficult to insert (especially larger prostheses) through short incisions. In our practice, we prefer the subfascial plane whenever possible, but the choice of the incision is determined by the patient's preference, anatomic characteristics, and the properties of the selected prosthesis.

There are great differences among the complication rates reported in the literature after breast augmentation surgeries. That the surgeries were performed by different surgeons, the differences in follow-up times and techniques, as well as the differences of manufacturers and types of prostheses can be named among the reasons. There are no direct correlations among decreased sensation in the nipple, sensation loss and size of implant, incision site, or implant position.[30] Brown found a 4% sensory loss at the nipple-areolar complex at 12 weeks after subfascial breast augmentation using a simple monofilament method.[30] While hematoma may necessitate a surgical intervention, infection necessitates the removal of the prosthesis. Other complications include seroma, asymmetry, malpositioning, capsule contracture, rippling, and wound dehiscence. Additional complications that can be seen with the transaxillary approach are subclavian and lateral thoracic vein thrombosis, lymphangitis of the upper arm, hypertrophic scar, subcutaneous fibrous band, long thoracic nerve injury, and ICBN injury (loss of sensation, numbness, and tingling on the inner side of the upper arm).

Subfascial breast augmentation is a safe and effective procedure that allows for predictable outcomes with excellent shape and longevity. In properly selected patients, this approach yields the benefits of both subglandular and submuscular placement without their shortcomings.[1],[2],[3],[4],[12],[14],[15],[16]

  Conclusion Top

Given the high blood supply to the subfascial plane and the presence of multiple septa, careful and meticulous dissection and hemostasis are needed to preserve the integrity of the fascia. It requires longer operating times and is a more difficult technique compared to other planes. Dissection by finger or using a dissector is difficult on the subfascial plane. There may be other difficulties depending on the place of the incision, including the difficulty of performing a dissection with a transaxillary approach at the inferior and the medial without using an endoscope and the difficulty of inserting large and highly cohesive gel-filled prostheses through this incision.

Augmentation with the subfascial technique provides predictable, consistent, satisfactory results, but these are not absolute rules, surgeons cannot perform the same operation in every augmentation mammoplasty case, nor can they always use the same incision, the same plane, and the same type of prosthesis. Surgeons should evaluate each patient individually and use their experience to make the best choice for their patients.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]

  [Table 1], [Table 2]


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