Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

2

Breast Augmentation: Subglandular, Subfascial, and Submuscular Implant Placement

C H A P T E R

Chet Mays and Bradley Calobrace

DEFINITION

Subfascial Implant

■■ Advantages to placing the implant in a subfascial pocket ( FIG 2 ) include the following 1,3 : 23 ■■ It avoids implant deformation or distortion (animation deformity) that can be seen in the subpectoral position. ■■ This position provides additional soft tissue coverage between the implant and the skin as compared to the sub- glandular pocket. ■■ Fascia provides additional support to minimize implant edge visibility and palpability seen most commonly with subglandular placement. ■■ Fascia provides support of implant especially in the upper pole minimizing excess implant movement and potential rotation with shaped implants. ■■ Less postoperative pain as compared to submuscular placement ■■ Fascia provides a distinct layer separating the implant from the overlying breast parenchyma. ■■ The disadvantages of a subfascial pocket include the following: ■■ Less soft tissue coverage compared to submuscular coverage

■■ A critical choice in breast augmentation is where to place the implant pocket. ■■ Subglandular ■■ Subfascial ■■ Submuscular (for purposes of this paper, submuscular refers to below the pectoralis major) ■■ Implant choice, size, and location are based on a variety of patient qualities. ■■ A biodimensional analysis is essential in determining the optimal implant type, size, and pocket location. There are many methods of evaluation. The High Five system described by Tebbetts is a systematic approach that illus- trates the most important aspects of evaluation, including the following: 24 ■■ Base width of breast ■■ Base width of implant ■■ Nipple to fold distance ■■ Estimate of final implant volume ■■ Pocket determination based on skin pinch thickness Subglandular Implant ■■ The subglandular implant is deep to the breast tissue and superficial fascia, but superficial to the deep pectoralis fas- cia, coming to rest on the inframammary fold ( FIG 1 ). ■■ The subglandular pocket has long been regarded as the most natural pocket. 2 ■■ The advantages of subglandular implant placement include the following: ■■ It avoids implant deformation or distortion that can be seen in the subpectoral position ■■ Enhances the improvement in the constricted or ptotic breast ■■ Allows an easier dissection plane ■■ Decreased postoperative discomfort ■■ Allows access to the inframammary fold (IMF) as the superficial and deep fascial components merge ■■ There are some disadvantages of the subglandular pocket, which include the following: ■■ Pocket with the least soft tissue coverage to disguise the implant ■■ Increased visibility or palpability of implant with wrin- kling or rippling ■■ Higher capsular contracture rate ■■ Less support and stabilization of the implants, especially shaped devices, compared to subfascial or submuscular pockets

FIG 1 • Subglandular implant placement is deep to the breast tissue but superficial to the pectoralis fascia.

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