What are the steps for performing subfascial breast augmentation on a healthy adult woman with no significant medical history?

Subfascial Breast Augmentation Surgical Technique

Subfascial breast augmentation places the implant above the pectoralis muscle but below the pectoralis fascia, offering superior lower pole coverage, reduced capsular contracture rates (approximately 1%), elimination of animation deformity, and faster recovery compared to submuscular placement. 1, 2

Patient Selection and Preoperative Planning

• Ideal candidates include patients with adequate soft tissue coverage who desire natural breast shape without implant animation during muscle contraction 1, 3
• Relative contraindications include extremely thin patients where implant edge visibility may still occur despite fascial coverage 1
• Smoking and obesity increase complication rates and should be addressed preoperatively 4
• Implant selection: Both smooth and textured implants can be used, though anatomical high-cohesivity gel textured implants have been extensively studied in this plane 3, 5

Surgical Technique: Step-by-Step Approach

Incision Options

Three approaches are well-documented for subfascial augmentation:

• Inframammary approach: Most direct access to the subfascial plane 1, 3
• Periareolar approach: Allows radial dissection perpendicular to skin incision 1, 3
• Endoscopic transaxillary approach: Provides inconspicuous scarring with endoscopic visualization 5

Dissection Technique

Initial dissection phase:

• After skin incision, dissect parallel to the skin (similar to skin-sparing mastectomy technique) for approximately 4 cm 3
• For periareolar approach, incise breast parenchyma radially (perpendicular to skin incision) and vertically until the fascial layer is reached 3
• Critical landmark: Identify the well-defined pectoralis major fascia as the dissection plane 3, 5

Pocket creation:

• Open the pectoralis major fascia and continue dissection craniocaudally underneath the fasciae of the pectoralis, serratus, and rectus abdominis muscles 5
• The subfascial plane provides a clear, relatively avascular dissection plane that is easier to develop than submuscular dissection 1, 3
• For endoscopic transaxillary approach, use endoscopic assistance to visualize and dissect the fascial plane safely 5

Modified dual-plane option:

• For patients with ptosis or tubular breast deformity, consider the subfascial mini-muscle release dual-plane technique 6
• Split the pectoralis major muscle 3 cm above the lateral margin, then proceed with submuscular dissection superiorly 6
• Divide a small portion of the costal origin inferomedially to create the dual plane 6

Critical Intraoperative Measurements

Achieve optimal aesthetic proportions by ensuring:

• Distance from inferior areolar border to inframammary fold: 6-7 cm 3
• Distance from superior areolar border to uppermost breast point: 9-10.5 cm (1.5X the inferior measurement) 3
• Distance between implants: 2-3 cm 3
• Distance from medial areolar border to midsternal line: 9-10 cm 3

Implant Insertion and Closure

• Insert the implant into the subfascial pocket with careful attention to positioning 1, 3
• Verify symmetric placement and appropriate implant position before closure 3
• Close the fascial layer if it was opened during dissection 3
• Close breast parenchyma and skin in layers 3

Expected Outcomes and Complications

Advantages of subfascial placement:

• Extremely low capsular contracture rate: Meta-analysis shows 1.01% across 3,743 patients 2
• No animation deformity: Implant remains stable with pectoralis muscle contraction 1, 2
• Excellent lower pole coverage: Superior to subglandular placement in preventing implant edge visibility 1
• Natural breast shape: Smooth transition between soft tissues and implant in upper pole 3
• Faster recovery: Less postoperative pain compared to submuscular placement 2

Reported complications:

• Infection rate: 0.1% 2
• Capsular contracture (Baker grade II): 16% in one series, though meta-analysis shows 1.01% overall 2, 5
• Occasional rippling, malrotation, axillary banding, sensory deficit, and asymmetry have been reported 2
• Hematoma, wound-healing issues, and implant malposition occur rarely 6

Common Pitfalls and How to Avoid Them

• Inadequate fascial dissection: Ensure complete fascial coverage by identifying and staying in the correct plane throughout dissection 3, 5
• Implant malposition: Verify measurements intraoperatively and ensure symmetric pocket creation 3
• Thin patients: Consider alternative planes (submuscular or dual-plane) in extremely thin patients where fascial coverage may be insufficient 1
• Inadequate hemostasis: The subfascial plane can have bleeding points; achieve meticulous hemostasis before implant insertion 3

Postoperative Monitoring

• Breast implants require regular monitoring for rupture starting at 5-6 years post-surgery, with imaging every 2-3 years thereafter 7, 8
• Implants do not require routine replacement at predetermined intervals; replacement is indicated only when complications occur 7, 8
• Patients should follow the same breast cancer screening protocols as those without implants, with additional implant-displaced views during mammography 8