Chapter-2-Breast-Augmentation_Subglandular-Subfascial-Submus

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Part 4 Plastic Surgery of the Breast

Pectoralis major

Pectoralis minor

FIG 6  • Histologic slide of the inframammary fold (IMF) showing the superficial and deep fascia fusing together. 7

■■ The subfascial pocket is deep to this deep pectoral fascia but superficial to the underlying muscle. ■■ This fascia is thin and more fragile in the lower two-thirds of the pectoralis muscle and becomes denser and substan- tial in the upper third of the muscle. ■■ The thin fascia in the lower aspects of the breast can make the initial subfascial dissection more challenging, which becomes easier as the dissection proceeds toward the upper pectoralis muscle. ■■ The deep fascia overlying the pectoralis and the deep layer of the superficial fascia underlying the breast unite with the dermis to form the IMF ( FIG 6 ). 7 PATIENT HISTORY AND PHYSICAL FINDINGS ■■ Initial consultation should evaluate the patient’s goals and anticipated results with the breast augmentation. ■■ A thorough history and physical should be done to iden- tify any risk factors for the procedure, including bleeding or clotting disorders. ■■ Any history of breast lumps, masses, or breast disease should be elicited. ■■ A family history is required. ■■ In planning for optimal implant pocket selection, it is important to determine the desired appearance or “look” the patient is seeking. ■■ The submuscular pocket is more likely to create a smooth, sloping upper pole with minimal roundedness in the upper pole. ■■ A patient desiring a more rounded upper pole with a more obvious “implant appearance” with implant shape visibility may prefer a subglandular implant, provided there is adequate soft tissue coverage. ■■ The subfascial approach can provide a compromise between the two; the implant will be in a plane similar to the subglandular, but the additional fascia layer will minimize implant edge visibility and palpability that can be seen with the subglandular pocket. ■■ The preoperative exam of the breast augmentation patient will guide the surgeon’s implant selection and pocket place- ment. The physical exam measurements should include the following ( FIG 7 ):

■■ There is loose areolar tissue between the deep layer of the superficial fascia and the fascia to cover the pectoralis major that and to cover the adjacent rectus abdominis, serratus anterior, and external oblique muscles. ■■ The deep pectoralis fascia has its origin on the clavicle and sternum, extending toward the lateral border of the muscle to form the axillary fascia ( FIG 5 ). ■■ It continues down to cover the latissimus dorsi muscle, rectus abdominis, serratus anterior, and external oblique. C FIG 4 (Continued)  • C. Muscular attachments to the chest. The pec- toralis major is removed on the right side of the picture revealing the underlying pectoralis minor.

Pectoralis major muscle

Skin

Retromammary space with overlying pectoralis fascia

Mammary glands

Ducts

Suspensory ligament

Fat FIG 5 • Breast anatomy showing pectoralis fascia posterior to the breast tissue.