Part 4 Plastic Surgery of the Breast

■■ Enhanced coverage of the implant ■■ Reduced issues with wrinkling ■■ Sloping natural upper pole ■■ Enhanced support for the breast implant ■■ Enhanced radiographic imaging with mammogram 5,22 ■■ The disadvantages of a submuscular pocket include the following: ■■ Animation deformity ■■ Increased risk of implant superior malposition with waterfall deformity ■■ Increased postoperative pain ■■ Limited expansion of the lower pole of breast (required to expand constricted and ptotic breasts) ■■ The most significant attribute of the submuscular pocket is in providing maximum soft tissue coverage for the implant. The widespread use of saline implants and wrinkling issues led to surgeons looking for improved implant coverage. After the moratorium on silicone was lifted, surgeons in the United States continued to use the submuscular pocket with mostly smooth and to a limited extent textured silicone implants. 6 ANATOMY ■■ An understanding of the breast blood and nerve supply is critical when performing breast surgery ( FIG 4AB ). ■■ Muscular attachments are shown in FIG 4C . ■■ The breast is a skin appendage contained within layers of the superficial fascia. ■■ The superficial layer of this fascia is near the dermis and is not distinct from it. ■■ The deep layer of the superficial fascia is more distinct and is identifiable on the deep surface of the breast when the breast is elevated in a subglandular augmentation mammoplasty.

Pectoralis major muscle

Pectoralis major fascia


FIG 2  • Subfascial implant placement is deep to the breast tissue and the pectoralis major fascia but superficial to the muscle.

■■ More challenging dissection to separate deep pectoral fas- cia from underlying muscle while keeping fascia intact. ■■ Higher rateof capsular contracture compared tosubmuscular Submuscular Implant ■■ Advantages to placing the implant in a submuscular pocket ( FIG 3 ) as compared to placement in the subglandular or subfascial pocket include the following: ■■ Lower capsular contracture rates 1,4

Pectoralis major

Pectoralis major

Pectoralis minor


FIG 3  • A. Submuscular position of the implant with overlying pectoralis muscle and breast parenchyma. Note that the released inferior edge of the pectoralis major allows lower pole expansion ( arrow ). B. Anterior view of the implant placement below the pectoralis major. A B

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