Subfascial Breast Augmentation: Surgical Guide for Plastic Surgeons

Subfascial breast augmentation is a specialized technique within the broader spectrum of breast augmentation procedures. This method involves placing the breast implant beneath the fascia, a connective tissue layer that lies between the breast tissue and the muscle. The subfascial approach offers several advantages, including a natural-looking result, reduced implant visibility, and potentially less postoperative pain. This comprehensive guide will delve into the various aspects of subfascial breast augmentation, providing a detailed resource for plastic surgeons.

Indications

Subfascial breast augmentation is indicated for patients seeking breast enhancement with a desire for a natural appearance and feel. It is particularly suitable for:

• Patients with moderate to good skin elasticity.
• Individuals with sufficient soft tissue coverage to conceal the implant.
• Patients who prefer a more natural contour and position of the implant.
• Cases where reduced postoperative pain is a priority.
• Situations where minimizing the risk of implant visibility and palpability is crucial.

Preoperative Evaluation

A thorough preoperative evaluation is essential to ensure optimal outcomes in subfascial breast augmentation. Key components of the evaluation include:

1. Medical History: Review the patient’s medical history, including any previous breast surgeries, medical conditions, allergies, and medications.
2. Physical Examination: Assess the breast anatomy, including skin quality, breast tissue thickness, and chest wall structure. Measure the base width, nipple position, and breast symmetry.
3. Patient Expectations: Discuss the patient’s goals and expectations. Use visual aids and previous case photos to align expectations with achievable results.
4. Imaging Studies: Consider mammography or ultrasound for patients over 40 or those with a family history of breast cancer.
5. Implant Selection: Discuss implant types (saline vs. silicone), shapes (round vs. anatomical), and sizes to determine the best fit for the patient’s anatomy and desired outcome.

Contraindications

Contraindications for subfascial breast augmentation include:

• Active infection in the body or breast area.
• Untreated or active breast cancer.
• Pregnancy or breastfeeding.
• Unrealistic patient expectations or psychological instability.
• Severe ptosis that requires a mastopexy instead of or in addition to augmentation.
• Insufficient breast tissue or thin skin that may not adequately cover the implant.

Surgical Techniques and Steps

Anesthesia

Subfascial breast augmentation is typically performed under general anesthesia, ensuring patient comfort and safety throughout the procedure.

Incision Placement

The common incision sites for subfascial breast augmentation include:

1. Inframammary Fold (IMF): The most common approach, offering direct access to the subfascial plane with minimal disruption to breast tissue.
2. Periareolar: Suitable for patients with smaller areolas and minimal ptosis, providing good access with minimal visible scarring.
3. Transaxillary: An endoscopic approach that avoids breast scarring but requires significant surgical expertise.

Creating the Subfascial Pocket

1. Dissection: Using precise surgical instruments, the surgeon dissects through the subcutaneous tissue to reach the pectoralis fascia.
2. Fascial Elevation: The fascia is carefully elevated off the underlying muscle, creating a pocket for the implant. This step requires meticulous technique to avoid damaging the muscle.
3. Hemostasis: Ensure thorough hemostasis to minimize postoperative bleeding and hematoma formation.

Implant Placement

1. Insertion: The selected implant is inserted into the subfascial pocket. Care must be taken to avoid contamination and ensure proper positioning.
2. Symmetry Check: The surgeon checks for symmetry and makes necessary adjustments to ensure a natural and balanced appearance.

Closure

1. Layered Closure: The incision is closed in layers, starting with the deep tissue and fascia, followed by the subcutaneous tissue and skin.
2. Dressing: Apply a sterile dressing and compression garment to support the breasts during the initial healing phase.

Postoperative Care

Effective postoperative care is crucial for optimal recovery and results. Key components include:

1. Pain Management: Prescribe appropriate analgesics to manage postoperative pain. NSAIDs and opioids are commonly used.
2. Activity Restrictions: Advise the patient to avoid strenuous activities and heavy lifting for at least six weeks.
3. Wound Care: Instruct the patient on proper wound care, including keeping the incision site clean and dry.
4. Follow-Up Visits: Schedule regular follow-up visits to monitor healing, address any concerns, and ensure proper implant positioning.
5. Compression Garment: Recommend wearing a compression garment or supportive bra for several weeks to minimize swelling and provide support.

Possible Complications

While subfascial breast augmentation is generally safe, potential complications include:

1. Infection: Prompt antibiotic treatment is necessary if signs of infection occur.
2. Hematoma: May require surgical drainage if significant.
3. Capsular Contracture: Formation of a tight scar capsule around the implant, potentially requiring revision surgery.
4. Implant Malposition: Requires surgical correction if the implant shifts from its intended position.
5. Rippling: More common with saline implants, visible or palpable rippling may necessitate a change in implant type or placement.

Different Techniques

Subfascial breast augmentation can be tailored using various techniques to suit individual patient needs:

1. Dual Plane Augmentation: Combines subfascial and submuscular placement, offering advantages of both techniques.
2. Fat Grafting: Used in conjunction with implants to improve contour and address areas of volume deficiency.
3. Hybrid Augmentation: Combining subfascial implants with fat grafting for enhanced aesthetic results.

Prognosis and Outcome

The prognosis for subfascial breast augmentation is generally excellent, with high patient satisfaction rates. Outcomes include:

• Natural Appearance: Achieving a natural look and feel is a primary benefit of the subfascial approach.
• Long-Term Results: With proper implant selection and surgical technique, results are durable and long-lasting.
• Minimal Complications: Lower risk of complications such as capsular contracture compared to other techniques.

Alternative Options

For patients not suitable for subfascial breast augmentation, alternative options include:

1. Submuscular Augmentation: Placing the implant beneath the pectoralis major muscle, offering additional soft tissue coverage.
2. Subglandular Augmentation: Placing the implant above the muscle but beneath the breast tissue, suitable for patients with adequate soft tissue coverage.
3. Autologous Fat Transfer: Using the patient’s own fat for breast enhancement, avoiding implants altogether.

Average Cost

The cost of subfascial breast augmentation varies based on factors such as geographic location, surgeon’s experience, and implant type. On average, costs range from $5,000 to $10,000, including surgeon’s fees, anesthesia, and facility charges.

Recent Advances

Recent advances in subfascial breast augmentation include:

1. 3D Imaging: Preoperative 3D imaging and simulation for precise surgical planning and patient communication.
2. Advanced Implant Materials: Development of highly cohesive silicone gel implants with improved safety profiles.
3. Minimally Invasive Techniques: Enhanced endoscopic tools for less invasive surgery and quicker recovery times.
4. Enhanced Recovery Protocols: Multimodal pain management strategies to reduce postoperative pain and accelerate recovery.

Conclusion

Subfascial breast augmentation is a versatile and effective technique for achieving natural-looking breast enhancement with minimized complications. By understanding the indications, surgical techniques, postoperative care, and potential complications, plastic surgeons can optimize outcomes and patient satisfaction.