Anatomical Implants in the Subfascial Plane

Background: In the last ten years, an increasing number of athletic women in whom it is important to preserve the pectoral muscle, are presenting for breast augmentation. This is the prime indication for augmentation in the subfascial plane using anatomical implants. Ideally, this result is less capsular contracture, more natural results and lower rotation index. However, a great degree of surgical precision is necessary. The pectoral fascia provides excellent coverage of the upper pole and also camouflages the implant borders, whether they are round or anatomic, because the fascia obscure the edges of the prosthesis. Anatomical devices with stable forms are superior to those implants with low cohesive filling. They also have low grade of capsular contracture, rippling and rupture leading to very natural results and high degrees of patient satisfaction.

Methods: A retrospective analysis of 9 years of patients who underwent breast augmentation from January 2009 to May 2018 was undertaken 728 patients under surgery, 579 with anatomical implants (80%) and 149 (20%) with round implants. All patient underwent primary bilateral augmentation in the subfascial plane. The implant sizes varied from 220 cc to 620 cc with 320 cc high profile implants most often employed. All patients were operated upon with local anesthesia and intravenous sedation, supplemented with intercostals and pectoral blocks, always administered by a Anesthetist. The surgery was ambulatory.

Results: For primary aesthetic breast augmentation the revision rate was 7.53%, necessitated by Baker grade III-IV 2.07%, infection 0.5%, explantation 0.5%, seroma 0.69%, rotation 2.07%, hematoma 0.5% and scar revision 1.2%. It is important  to highlight that there were no cases of breast implant-associated ALCL in our patients, recognizing that Argentina has reported only one case of ALCL. While the appearance that each patient prefers is highly  subjective, the anatomical implant is frequently preferred by patients who desire a natural results. As is the case in every augmentation mammoplasty, breast shape and width, the height of the lower pole, ptosis of the breast, skin quality, asymmetries, chest wall anomalies and the amount of the soft tissue coverage needs to be critically considered in each case. It is necessary to perform  surgery precisely to decrease the degree of rotation and to use implants with a larger vertical length to limit the horizontal dissection of the pocket.

Conclusions: Patients older than 35 years of age aften prefer anatomical devices for more natural results. For the slim athletic patients who have little coverage of tissue and need to preserve the pectoral muscle, the subfascial plane is an excellent option. These patients have less pain in the post-operative period due to the lack of pectoralis muscle incision, have less a requirement for pain killers with less potential addiction to opioid medication and have less disruption of tissue with high degrees of patient satisfaction.

BIBLIOGRAPHY

• Graf RM, Bernardes A, Rippel IR, Damasio RC, Auersvald A. Subfascial breast implant: A new procedure. Plast Reconstr Surg. 2003,111:904-908.
• Mallucci P, Brandfort OA. Design for natural breast augmentation; The ICE principle. Plast Reconstr Surg. 2016;137:1728-1737.