A Comprehensive Outcome Review of Subfascial Breast Augmentation over a 10-Year Period

Outcomes in Subfascial Versus Subglandular Planes in Breast Augmentation: A Systematic Review and Meta-analysis

Breast augmentation is the most commonly performed aesthetic surgery procedure in women worldwide. The use of the subfascial plane has been suggested to decrease the incidence of capsular contracture compared with the subglandular plane, while simultaneously avoiding the complication of animation deformity in the subpectoral plane. The aim of this systematic review and meta-analysis was to compare the adverse outcomes of subfascial vs subglandular planes in breast augmentation. This review was registered a priori on OSF (https://osf.io/pm92e/). A search from inception to June 2023 was performed on MEDLINE, Embase, and CENTRAL. A hand search was also performed. All randomized and comparative cohort studies that assessed the use of the subfascial plane for breast augmentation were included. Outcomes evaluated included the incidences of seroma, hematoma, infection, rippling, capsular contracture, and revision surgery. Ten studies were included in this systematic review. Three randomized controlled trials and 7 comparative cohort studies were used for quantitative synthesis. There was a significant difference favoring subfascial compared with subglandular planes in the incidence of hematoma, rippling, and capsular contracture. All included studies had a high risk of bias. The current evidence suggests that the subfascial plane for breast augmentation decreases the risk of capsular contracture, hematoma, and rippling compared with the subglandular plane. Further randomized evidence with high methodological rigor is still required to validate these findings.

LEVEL OF EVIDENCE: 3

Aqua Breast Augmentation (ABA): Hydrodissection Breast Augmentation Technique

INTRODUCTION

Breast augmentation is a prevalent procedure in plastic surgery. In this article we present the Aqua Breast Technique (ABA), an approach aimed at enhancing patient satisfaction and reducing downtime. This technique leverages tumescent anesthesia and a small incision in the inframammary fold, avoiding electrocautery and surgical drains, to fulfill the growing demand for painless procedures with minimal recovery periods.

MATERIALS AND METHODS

The study retrospectively analyzed 238 patients who underwent breast augmentation using the ABA technique at Instituto Rubi between 2021 and 2024. The ABA protocol involves detailed preoperative design, local anesthesia, a precise 3-centimeter incision, careful dissection, and specific postoperative care, emphasizing hydrodissection for tissue separation and the use of smooth round silicone implants through a Keller funnel.

RESULTS

The application of the ABA technique to 238 patients, with a mean follow-up time 14 months. Ten patients required surgical intervention due to complications. Hematoma and infection rates were 0.42%, while capsulectomies were required in 2.1% of cases.

CONCLUSIONS

Aqua Breast Augmentation technique has been successfully applied as a hydrodissection-based breast augmentation technique method, with low complication rates, short downtime, and reduced postoperative pain. Level V, therapeutic study.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Reverse Dual Plane: A Novel Technique for Endoscopic Transaxillary Breast Augmentation

Background

Quite a few Asian patients prefer axillary incision for breast augmentation. However, this surgery needs improvement.

Objectives

To introduce a reverse dual-plane technique through a transaxillary approach and compare it with a transaxillary dual-plane approach.

Methods

Eighty-two patients were divided into Group A (n = 40) and Group B (n = 42). Axillary incision and endoscope were utilized in the 2 groups. Tebbetts' dual plane was performed in Group A patients. Patients in Group B underwent our reverse dual-plane technique, in which the upper 70% was subfascial and the lower 30% was subpectoral, with the fascia of the external oblique and anterior serratus being elevated together with the pectoral muscle. The Numeric Pain Rating Scale (NPRS) scores were recorded daily for 7 days. Breast shape and softness, in both sitting and supine positions, were assessed by the patients, and complications were compared.

Results

The NPRS scores of Group B patients were significantly lower than those of Group A patients (P < .01). The satisfaction rate of shape and softness in the seated position was not significantly different (P > .05). However, in the supine position, only 20 patients (50.0%) in Group A and 32 patients (76.2%) in Group B were satisfied with their breast softness (P < .01), and the breasts of the others became stiffer. Breast animation deformity (BAD) occurred in 2 patients in Group A and in no patient in Group B (P < .01). Other complications were not significantly different.

Conclusions

Compared with Tebbetts' dual plane, this procedure significantly reduced pain, improved breast softness, and eliminated BAD, without increasing complications.

Level of Evidence 4

The Position of the Nipple-Areola Complex in Breast Augmentation

BACKGROUND

There is some controversy regarding whether the nipple-areola complex (NAC) is elevated, remains stable, or is lowered in breast augmentation. There is a general belief that one can modulate its position depending on the implant chosen. In addition, many preoperative markings include elevating the arms to predict the final position of the NAC.

OBJECTIVES

The aim of this study was to investigate changes in the position of the NAC and determine whether the postoperative position of the NAC can be predicted preoperatively by elevating the arms.

METHODS

The study included 45 patients. A 3-dimensional scan was performed to take basal (preoperative) and 12-month measurements with the patient's arms in abduction and elevated over the head. The distances measured were the sternal notch-nipple (SN-Ni), nipple-nipple (Ni-Ni), and nipple-inframammary fold (Ni-IMF) distances.

RESULTS

With arms abducted, the SN-Ni distance increased by 6% when measured linearly, 8.5% when measured on the skin surface, and 1% to 2% when measured on the sternal line. The Ni-Ni distance increased by 9% (linear) and 15% (over the surface). The Ni-IMF increased by 44%. With arms adducted, the SN-Ni distance increased by 9% (linear), 12% (on the skin surface), and 0.5% at the sternal midline projection. The Ni-Ni distance increased 11% (linear) and 19% (on the surface). The Ni-IMF distance increased by 53%. The postoperative position of the NAC with the arms abducted increased by 17% compared with the preoperative position in adduction.

CONCLUSIONS

Implants do not elevate the NAC; its position remains nearly unaltered. The SN-Ni distance was increased in 90% of the patients. Lifting the arms for preoperative markings does not help to predict the postoperative position of the NAC.

LEVEL OF EVIDENCE: 4

Biomechanical Principles of Breast Implants and Current State of Research in Soft Tissue Engineering for Cosmetic Breast Augmentation

Currently there are limited implant-based options for cosmetic breast augmentation, and problems associated with those have been increasingly appreciated, most commonly capsular contracture, which occurs due to a chronic foreign body reaction against non-degradable implant materials such as silicone and polyurethane leading to scar tissue formation, pain, and deformity. The underlying biomechanical concepts with implants create a reciprocal stress-strain relationship with local tissue, whilst acting as a deforming force. This means that with time, as the implant continues to have an effect on surrounding tissue the implant and host's biomechanical properties diverge, making malposition, asymmetry, and other complications more likely. Research directed towards development of alternative therapies based on tissue engineering and regenerative medicine seeks to optimize new tissue formation through modulation of tissue progenitors and facilitating tissue regeneration. Scaffolds can guide the process of new tissue formation by providing both an implant surface and a three-dimensional space that promotes the development of a microenvironment that guides attachment, migration, proliferation, and differentiation of connective tissue progenitors. Important to scaffold design are the architecture, surface chemistry, mechanical properties, and biomaterial used. Scaffolds provide a void in which vascularization, new tissue formation, and remodelling can sequentially occur. They provide a conduit for delivery of the different cell types required for tissue regeneration into a graft site, facilitating their retention and distribution. Whilst recent research from a small number of groups is promising, there are still ongoing challenges to achieving clinical translation. This article summarizes the biomechanical principles of breast implants, how these impact outcomes, and progress in scaffold-guided tissue engineering approaches to cosmetic breast augmentation. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Analysis of Ptosis following Subfascial Breast Augmentation: Calculations That Explain Dogma

BACKGROUND

Implant placement can improve ptosis due to the position of the nipple, inframammary crease, and base of the breast acting together. The interrelationship between these was quantified via changes in morphometry following subfascial augmentation, and explains the circumstances under which dogma holds true.

METHODS

One hundred seventy-five patients underwent a series of static measurements before and 3 months after subfascial breast augmentation. Ptosis in the nipple and base of the breast was calculated before and after surgery.

RESULTS

All measurements except that of the the lateral sternal margin increased after surgery. All grades of ptosis reduced following surgery. There was lowering of the base in grade 1 patients, but not for other grades. Increased base ptosis correlated with reduced lateral sternal margin (1.9 cm compared with 2.9 cm; left, H5 = 24.7, p < 0.01; right, H5 = 24.5, p < 0.01). Implant volume did not correlate with change in ptosis at the nipple or base. Reduced ptosis was associated with implants that are a narrow match of implant to breast (0.52 to 0.95) (left, H5 = 28.3, p < 0.01; right, H5 = 24.9, p < 0.01). Decreasing ptosis correlated with lower lateral sternal margin compared to breasts that increased ptosis. Change in ptosis following surgery does not correlate with having children.

CONCLUSIONS

Subfascial placement has varying effects on ptosis. Non-ptotic or mildly ptotic breasts appear to improve due to a disproportionate descent of the inframammary crease relative to the nipple and base. Patients with little breast tissue are more susceptible to an increase in "bottoming out," particularly if broad implants are used. A ratio matching implant to the base width has predictive value on outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.