BSAPS Journal

Introduction:

Breast augmentation, also known as augmentation mammoplasty, is a surgical procedure where breast implants are inserted beneath the breast tissue/chest muscle to improve breast size. Breast augmentation is a technique for most women to increase their confidence¹. There are various types of breast implants, such as gel implants and saline implants. They can be round or anatomical depending on the shape. Based on the profile they can be either low profile, medium or high profile. According to the surface, the implants are smooth, textured or micro textured². Reasons why women want breast implants includes boosting in their self-esteem by increasing the size of disproportionally small breasts, when one breast is larger than the other, and women who had a mastectomy. Breast augmentation surgery involves surgically inserting an implant behind each breast³. Breast augmentation is a major positive step for most women. Studies have shown that breast implants can help boost self-esteem, body image, and marital harmony⁴. Subfascial augmentation is a method originally developed to minimize the risk of capsular contracture, and decrease the postoperative pain which is sometimes associated with sub-pectoral augmentation⁵. Subfascial breast augmentation was pioneered in Brazil by Dr. Ruth Graf in 1998 and currently, this procedure has earned interest in the aesthetic world⁶. Breast implant surgery was commenced in Bangladesh in September 2001⁷. In sub-glandular augmentation the implant is positioned between the Pectoralis Major and glandular tissue of the breast⁸. When the fan-shaped Pectoralis major muscle is divided inferiorly along the ribs, and the implant placed underneath, it is known as sub-pectoral implant⁹. There are some statistical differences between subfascial and subpectoral/subglandular implant placement in terms of breast shape and contour, capsular contracture, implant base and the appearance of folds. Studies show subfascial breast augmentation to be better than subglandular breast augmentation¹⁰. Recent development in technique and implant quality has contributed to more natural looking results¹¹. Silicone gel breast implants are preferred among plastic surgeons rather than saline implants due to better availability and cost difference¹². The most commonly employed incision for breast implant insertion is the infra-mammary incision. It can also be inserted through a peri-areolar incision. The incision is small and inconspicuous in this location¹³. More than 2 million women have received breast implants in the United States over the past 30 years. Nearly 20% of breast implants are used for reconstruction in breast cancer patients following mastectomy¹⁴. Some of the complications that may arise after breast augmentation, include breast pain, changes in the nipple and breast sensation, infection, capsular contracture, implant displacement, implant rupture and connective tissue disease¹⁵. Recently ALCL (Anaplastic Large Cell Lymhoma) has been linked to breast implant surgery on very rare occasions. In the United States, women of all ages mostly 18 to 70 years do breast augmentation. The average patient age undergoing breast augmentation is 35 to 50 years¹⁶. Due to skepticism and unawareness breast augmentation was not very commonly performed in Bangladesh before. However, the popularity of breast implant surgery is increasing rapidly¹⁷. The aim of the study was to investigate the outcome of subfascial placement of breast implant for augmentation, rather than the more traditional submuscular or subglandular placement.

Methods:

A retrospective cross-sectional study was carried out in the Bangladesh Specialized Hospital and Cosmetic Surgery Centre Ltd during the period from January 2018 to January 2021. A total of 15 patients (N=15) over the period of three years were enrolled in this study following the inclusive criteria. Data were collected using the predesigned semi-structured questionnaire. All patients underwent sub-fascial breast augmentation surgery with the silicone implant. Patients were followed-up at one month, at the sixth month, at 1st year, at 2nd year and at 3^rd  year. Eight patients completed their three years follow-up, four patients completed their follow-up at 2nd year. Furthermore, one and two patients completed their one-year follow-up and at the three-month follow-up after surgery. All the patients recovered smoothly. Most of the patients return to normal office work within one week of surgery. None of the cases developed capsular contracture. There was no distortion of the implant. Verbal consent was taken before recruiting the study population. The information was kept confidential only to be used for the study purpose.

Inclusion criteria:

Patients who underwent breast augmentation surgery for aesthetic purposes.

Exclusion Criteria:

Patients who underwent reconstruction following mastectomy due to malignancy or prophylactic mastectomy.

Patients who showed unwillingness to participate in the study.

Data analysis:

Random checks were done to ensure that data collection procedures were followed. Completed data forms were examined, amended, and processed for computer data input. Frequencies and percentages were used for descriptive analysis. The data analysis was performed using Statistical Package for the Social Sciences (SPSS) Version 25.0.

Anatomy & Surgical Technique:

Under general anesthesia and supine position, inframammary incision was used. After skin and subcutaneous tissue were divided, the fascia over the pectoralis major muscle was incised. Pectoral fascia is a layer of fibrous tissue over the pectoralis major muscle. The lower portion of the fascia is relatively thin, but gradually becomes thicker superiorly. The fascia can be readily raised from inframammary approach. Raising the fascia from periareolar incision is also possible. A combination of sharp and blunt dissection is used. Diathermy can also be used as required. Dissection is done up to 2nd intercostal space superiorly and medially 2 cm away from the midline, inferiorly 2 cm from the inframammary crease. The implant was then introduced. Closure is done by 2/0 vicryl for deeper tissues and 4/0 vicryl was used for intradermal skin closure. No drain tube was used. Patients were instructed to avoid lifting heavy weight for 4 to 6 weeks.

Results:

Among the study population (N=15) patients were aged from 18 to 40 years. The mean age of the samples was 28.67±SD, and the maximum and the minimum age of the study population were 40 and 18 respectively. Around two-fifths of the study population (40%) completed higher secondary levels, one patient (6.66%) completed secondary levels, four patients (26.7%) were graduates, one-fifth of the study population (20%) completed Master’s degree and only one patient (6.66%) was a doctor. Four patients (26.67%) were actresses and models, one-fifth of the study population (20%) were housewives, one-fourth (26.67%) of the study population were job holders, and four patients (26.67%) were students. 80% of the study population underwent this surgery to improve body image and the rest of 20% of the study population were keen on breast augmentation surgery to improve their self-confidence.

Table 1: Characteristics of Study Population (N=15)

Fig 1: Subfascial pocket dissection and fibers of Pectoralis Major muscle (per-operative)

Mean breast size before breast augmentation was 33.20±SD and the minimum breast size was 32 and the maximum breast size was 36. No complication was observed during the postoperative period and follow-up at the one month, sixth month, 1st year, 2nd year and at 3rd year follow-up after surgery were recorded. No capsular; contracture, or post-operative wound infections were seen and no animation deformity was reported during the study period.

Fig 2: before and after one month of breast augmentation

Fig 3: before and after images following subfascial breast augmentation surgery after 6 months.

Fig 4: before and after images following subfascial breast augmentation surgery, done as part of “mommy makeover”

Discussion:

In the current study, all of the study population underwent subfascial breast augmentation surgery. None of the patients (N=15) developed any complications during the post-operative period and during follow-up. The level of satisfaction was assessed six months after the procedure. During six months after surgery, breast shape continues to change and edema might cause potential volume distortion and asymmetry¹⁸.

Fig 5: Same patient as in Figure 4 in right oblique view.

Several studies show the sub-muscular placement of implants have animation problems whilst sub-glandular placement confers little coverage especially in small breasts^19,20. Subfascial placement helps prevent animation problems commonly seen after sub-muscular implant placement. Sub glandular placement has advantages of easier dissection and rapid recovery but it has disadvantages like rippling, upper pole step deformity, inadequate coverage and more prominence of the implant due to superficial placement.

Gould et. al. (2020) found that subfascial breast augmentation surgery has a lower risk of capsular contracture compared with sub-glandular and submuscular breast augmentation. Submuscular implant placement leads to more animation of the implant with muscle contraction during movement of the arm⁶. Different studies suggested that subfascial breast augmentation surgery has fewer complications in comparison with other breast augmentation surgery procedures. It has the advantage of avoiding division of the Pectoralis Major muscle and less post-operative pain due to less tissue dissection²¹.

In the present study, only silicone gel implant was used. The latest generation of silicone gel implants and subfascial approaches has enhanced aesthetic outcomes following breast augmentation²².

Breast augmentation to enhance the shape and the size of the breasts is well established for restoring and rejuvenating femineity²³.

Breast augmentation is a well-known procedure and continues to be one of the most frequently performed aesthetic surgeries worldwide²⁴. The cardinal characteristic of subfascial breast augmentation is the creation of a strong support system for the implant’s upper pole. Displacement in this position is avoided by placing the upper pole between muscle and fascia which constitutes a strong support system compared to sub-glandular approach²⁵.

Subfascial breast augmentation was started with a view to lessen the incidence of capsular contracture while at the same time reducing postoperative morbidity related with subpectoral augmentation²⁶. Another advantage of Subfascial breast augmentation surgery is the implant remains secured in place and a natural outcome is heightened since the skin and subcutaneous tissue in the upper third of the pocket are not directly in contact with the implant. In case of sub glandular placement, the implant is more prominent due to less coverage and direct contact of the implant with the subcutaneous tissue in the upper part pf the breast.  Therefore, subfascial breast augmentation technique reduces visibility of the edges of the implant on the skin, making them less prominent. The stronger support system that results from the subfascial placement of the implant prevents the implant’s shape and position from altering.  Subfascial breast augmentation has distinct benefits as it combines the advantages of the sub-glandular approach like more exact control of both breast shape and inframammary fold positions, more expeditious postoperative recovery, and lack of distortion²⁷.  Disadvantages of the subpectoral approach such as malposition over time, the tendency for lateral displacement, increased morbidity in case of recovery from pain, and the inframammary fold’s malposition have been considerably lessened by using the subfascial technique²⁸. The subfascial breast augmentation technique suggests enhanced long-term aesthetic results. This technique is flexible and may also be used in the study population requiring the removal and replacement of breast implants.

Conclusion:

Precision in surgical technique during breast implant surgery with silicone implants can decrease the risks of complication. Subfascial breast augmentation provides natural looking results, providing adequate implant coverage, thus preventing palpability and visibility of implants. Postoperative pain is less and implant animation during arm movement can be avoided. Overall patient and physician satisfaction are high. Thus subfascial breast augmentation with silicone implant has now become the preferred technique for breast augmentation for many plastic surgeons across the globe.

Recommendation:

Further research is needed to get robust data to conclude a better aesthetic outcome and study the populations’ satisfaction with sub-fascial breast augmentation surgery with

silicone implants.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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