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Augmentation Mammaplasty with Anatomic Soft, Cohesive Silicone Implant Using the
Transaxillary Approach at a Subfascial Level with Endoscopic Assistance

Jose Mari´a Serra-Renom, M.D., Ph.D., Manuel Ferna´ndez Garrido, M.D., and TaiSik Yoon, M.D. Barcelona, Spain.

Background: Many augmentation mammaplasty techniques have been developed paying special attention to incision location and pocket plane to achieve more naturallooking

Methods: The authors’ technique of choice in patients with mammary hypoplasia, empty
breasts following a diet program, or more than one lactation episode causing skin flaccidity
without ptosis is the placement of an anatomical implant using a transaxillary approach in a subfascial plane with endoscopic assistance. Thus, ideal patients are those presenting
mammary hypoplasia, empty breasts following two or more lactation episodes, and breast skin flaccidity without ptosis, with the nipple-areola complex placed above the inframammary fold. The technique and its indications are presented thoroughly.

Results: Forty-five patients were operated on using this technique from May of 2001 to
October of 2003. One-year follow-up results showed highly rated patient satisfaction. One
patient underwent an implant exchange because of implant size dissatisfaction.

Conclusions: The authors prefer subfascial plane implants to submuscular ones. Possible
rotation of anatomic implants and the subsequent asymmetry when contracting the pectoral muscle are avoided. Pectoral muscle is not detached from its insertions, resulting in less postoperative pain. Likewise, the authors prefer a subfascial to subglandular pocket since the weight of the subglandular pocket and the glandular weight itself are borne by the skin envelope leading to breast ptosis development over time. On the other hand, fascia provides additional support to the subfascial implant, thus eliminating ptosis development and achieving good filling of the upper pole similar to the filling provided by subglandular implants. (Plast. Reconstr. Surg. 116: 640, 2005.)

-From the Department of Plastic and Reconstructive Surgery at University Clinic Hospital, University of Barcelona Medical School, and Aesthetic
Surgery Institute Dr. Serra-Renom. Received for publication March 3, 2004; revised November 23, 2004. DOI: 10.1097/01.prs.0000173558.52280.6e -

When undertaking augmentation mammaplasty, we prefer to use soft, cohesive, silicone
anatomical implants compared with the traditional round implants1 since soft, cohesive, silicone implants allow a wide spectrum of options with regard to shape, height, width, and
projection to achieve appropriate filling of the lower pole and match the particular needs of
each individual. We prefer the transaxillary approach because it provides direct access to the subglandular, subfascial, and submuscular planes, resulting in the most inconspicuous
postoperative scar and integrity of the breast tissue.2,3

The aesthetic result achieved by placing the implant in the subglandular plane is satisfacperiod. Because the skin bears the weight of the implant and the gland itself, ptosis develops over time, especially if skin flaccidity is present. By placing the implant in a subfascial plane, the firm fascia of the pectoralis major muscle provides additional support to the skin helping to bear the weight of the prosthesis and avoiding the development of ptosis in the late postoperative period. Submuscular implants may lead to implant malpositioning, implant distortion during pectoralis muscle activity, and significant postoperative pain, since the muscle is detached from its insertions. An implant in a subfascial plane benefits from additional softtissue coverage of the implant and avoids the drawbacks of submuscular location.



The ideal candidate for this technique is a woman with one of the following characteristics:
mammary hypoplasia; empty breasts after two or more breast-feeding episodes with cutaneous flaccidity in the absence of ptosis; or empty breasts after a diet program with skin flaccidity in the absence of ptosis, with the nipple-areola complex above the inframammary fold from the lateral view.


Our technique is described below. First, an incision is made at approximately 4 to 5 cm below the axillary fold, from the anterior axillary line, but never crossing beyond the lateral edge of the pectoralis major muscle.

Once the skin incision is made, the superficial fascia of the pectoralis major muscle is identified and an incision is made parallel to the fibers along the edge of the muscle.
Subfascial dissection is performed under the fascia of the pectoralis major muscle and above the muscular fibers with the aid of an endoscopic swivel retractor, which we designed.9 When the most distal margin is reached, the fascia is incised horizontally at the level of the sixth rib and subcutaneous-subglandular dissection is carried on downward to the new location of the inframammary fold.

A saline-filled measuring implant is placed to determine appropriate anatomical implant volume and size, as well as to assess bilateral symmetry. The measuring-implant is removed and hemostasis is reviewed thoroughly by endoscopy.

The reference points for the prosthesis are plotted on the skin with the aid of a pattern
taken from the prosthesis. The anatomical implant is placed using two specially designed
retractors to allow simultaneous separation of the pectoralis major and serratus muscles. The reference points are assessed under endoscopic view to ensure correct placement of the prosthesis.

Aspirative drainage is placed and the axillary incision is closed. A dressing is carefully placed to maintain the implant in the appropriate position during the first week to avoid rotation due to any involuntary movement of the patient.

Thereafter the patient should sleep in a supine decubitus position with a brassiere to
maintain the position of the implant (Fig. 1).


From May of 2001 to October of 2003, we have operated on 45 patients using this technique resulting in uneventful postoperative recovery without any discomfort. The patients’ ages varied from 22 to 48 years (mean, 33 years). No patient with breast ptosis underwent this technique, although patients with skin flaccidity were operated on. In all cases, the nipple- areola complex was placed above the inframammary fold from the lateral view. The sizes of the implants (McGhan medium heightmedium projection and medium height-full projection) varied from 260 cc to 360 cc; the most frequently used implants ranged between 280 cc to 320 cc. Neither rotation nor prosthesis displacement has been observed. Uppermammary- pole fullness has been adequate with anatomical implants. In very thin patients having a “pinch test” result (a measurement of the thickness of the skin and the subcutaneous tissue when pinched between two fingers) of less than 1 cm, the upper edge of the prosthesis was slightly conspicuous. Axillary scars have evolved very satisfactorily with no case of hypertrophy or intercostobrachial nerve injury.

Preoperative and one-year postoperative views of two patients are shown in Figures 2 and 3. Patients were reviewed one day postoperatively, after a week, a month, and 3 months,
and at the end of the first postoperative year.

The following items were assessed thoroughly: symmetry; appropriate placement of the implants with or without rotation; the height of the implant; and the presence of capsular contracture (Fig. 3).

The results were very satisfactory with regard to the volume and the final shape of the breast. In only four patients with a “pinch test” result of less than 1 cm was the upper edge of the prosthesis slightly conspicuous. No capsular contracture, wrinkling or rippling was found during the follow-up appointment. Patient satisfaction was assessed using a 0 to 5 scoring system to indicate the patient’s satisfaction with the final outcome, and using a 0 to 10 scoring system to indicate satisfaction with volume, symmetry, and breast separation or gathering.

The implant was replaced in one patient who considered the implant to be too big.
During the first review, all patients were satisfied with the shape but 90 percent thought
the implants were too big. In the one-month review, 40 percent of patients still thought the
implants were big although they liked the shape. In the 3-month review, all patients were
satisfied with the shape and the size but one. In that patient, the McGhan medium heightmedium projection 320-cc implant was replaced by a McGhan medium height-medium projection 260- cc implant. Paradoxically, at the end of the first postoperative year, 15 percent of the patients were still satisfied with the shape of the breasts but would have chosen a bigger implant.
These patients were told that according to their thoracic diameter, the size of the implants was suitable. They remained satisfied.


Our experience with the transaxillary approach to placement of anatomical implants in a submuscular plane is very satisfactory. Over four years, we have operated on 160 patients with mammary hypoplasia. Nine patients were reoperated on because unilateral rotation of the prosthesis caused unsuitable breast shape according to the anatomical shape of the implant. Within the first 2 weeks of the postoperative period, three patients experienced rotation due to the development of a small hematoma.

Unfavorable breast shape developed in 35 cases when patients contracted the pectoralis
muscles by pressing their palms together with the elbows in an abducted and flexed position.

Twelve patients presented with hematoma during the immediate postoperative period. Three required reoperation to remove the hematoma with implant reinsertion. In all cases, the pain and discomfort during the immediate postoperative period were noticeable. The endoscopic retractor designed by the senior author9 (Snowden Pencer, Serra-Renom Endoscopic Swivel Retractor System p(88-5140)) was utilized in all cases.

During the same period, 18 patients presenting with skin flaccidity without ptosis underwent
transaxillary subglandular placement of anatomical implants. All these patients presented
with a nipple-areola complex located above the inframammary fold in the lateral view.

Fourteen patients developed empty breasts after one or two breast-feeding episodes; four patients developed empty breasts after following a diet program. In these cases, we achieved good filling and fullness of the pocket by placing the prosthesis behind the gland, which is technically easier. There is, however, the inconvenience of ptosis due to the weight of the gland and the weight of the implant being borne totally by the skin, since
subglandular dissection splits up the support ligaments between the deep layer of the superficialis fascia and the pectoralis fascia.

The Cooper ligaments constitute a dense conjunctive tissue coming from the overlying
skin into the breast, passing through the glandular tissue, and reaching the superficialis fascia, which covers the anterior and posterior glands and provides subjection and conical
shape. Similarly, there are fibers joining this deep layer of the superficialis fascia to the superficial layer of the pectoralis major muscle fascia. Placing the implant in a subglandular
plane provides satisfactory outcomes immediately postoperatively but the weight that the
skin is bearing increases, and ptosis develops over time.

Subfascial placement of anatomical implants provides a proper filling of the cutaneous
pocket and the upper pole and corrects skin flaccidity, which is achieved because the implant is placed behind the gland. The immediate postoperative recovery is better, with less pain and discomfort.5,6 Likewise, physical activity, including pectoralis muscle contractions do not jeopardize implant position because it is at a subfascial plane.7,8 The incidence of breast ptosis does not increase after the first postoperative year with subfascial implants because the fascia, in part, bears the weight of the implant and the mammary gland. Similarly, the incidence of ptosis does not increase because fibrous attachments between the deep layer of the fascia superficialis and the pectoralis muscle
fascia are preserved. The section of the fascia at the sixth rib level allows better projection of the lower gland pole. With this technique, implant malpositioning (rotation) due
to muscular contraction is avoided.2,7

When patients with cutaneous flaccidity but no ptosis from the lateral view are treated incorrectly using a mastopexy with or without prosthesis, the nipple-areola complex is located at a very high position, causing a conspicuous scar, which is irreversible. We believe that an anatomical breast implant placement in a subfascial plane utilizing the transaxillary approach combines the advantages of the subglandular and submuscular planes and avoids their disadvantages. Technically, the transaxillary approach for the subfascial implant is more complicated than subglandular or submuscular placement, but with the aid of the swivel retractor for the pectoralis major and serratus muscles and the endoscopic view, the difficulty decreases greatly.

When using soft, cohesive, silicone gel anatomical implant, the transaxillary insertion becomes easier because the implant is softer. The transaxillary approach is performed by dissecting a pocket with endoscopic assistance and using a measuring implant to assess the accurate size of the implants required as well as the symmetry between the two pockets before placement of the definitive prosthesis. The postoperative dressing is very important to avoid rotation of the implant. The patient should sleep in a supine decubitus position for one month.

In patients with empty, flaccid breasts, as often occurs after one or more lactation episodes, the technique of choice in our institute is the subfascial placement of soft, cohesive, silicone gel anatomical implants through the transaxillary approach with endoscopic assistance

Jose Mari´a Serra-Renom, M.D., Ph.D.
Aesthetic Surgery Institute Dr. Serra-Renom
Virgen de la Salud 78-5° E
Cli´nica Quiro´n
Barcelona, Spain


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8. Stoff-Khalili, M. A., Scholze, R., Morgan, W. R., and Metcalf, J. D. Subfascial periareolar augmentation mammaplasty. Plast. Reconstr. Surg. 114: 1280, 2004.
9. Serra-Renom, J. M. Retractor with mobile endoscope. Plast. Reconstr. Surg. 100: 529, 1997.

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