Submuscular Vs. Subfascial Breast Augmentation: A Shift Towards Stability

Goals/Purpose: With prepectoral placement gaining popularity and becoming the standard for implant based breast reconstruction, our experience with prepectoral implant placement has rapidly grown. Inspired by the benefits of prepectoral reconstruction, we have revisited prepectoral implant placement for breast augmentation. Propelled by continued good results, we have begun to shift the majority of our breast augmentations to placement in the subfascial plane. Contrary to traditional teaching regarding increased rates of capsular contracture the prepectoral pocket, anecdotally we had not noticed any capsular contracture in our subfascial augmentations. Additionally we were noticing less malposition and double bubble deformity among the subfascial patients. Reflecting upon these observations, we undertook a comprehensive review of the last decade of consecutive breast augmentations performed by a single surgeon. The goals of this study were to compare the results of submuscular vs subfascial breast augmentation for differences in capsular contracture, double bubble deformity, malposition, and complication rates.

Methods/Technique: Retrospective review was performed on all patients having undergone breast augmentation in the last 10 years for a single surgeon, identifying 598 patients. Individual patient records were reviewed and after excluding all patients with textured implants, breast reconstruction, chest radiation, non-inframammary fold incision placement, subglandular placement, missing records, absent postoperative photography, or follow-up less than 1 month, 135 total patients (270 breasts) met criteria for inclusion. A thorough review of each of the remaining 135 patient’s charts and photography was conducted. Records and photographs were examined for capsular contracture (grade 2 or higher), lateral malposition, double bubble deformity, and complications. Other points collected included age, date of surgery, date of latest followup, date of capsular contracture identification, medical comorbidities, body mass index, implant type, size, use of radial release, presence of combination cases, use of fat grafting, mastopexy, and use of singulair.

Results/Complications: Of the 270 breasts, 192 were submuscular placement and 78 were subfascial placement. The submuscular group had an average implant size of 342.34 cc and the subfascial group had an average implant size of 337.82 cc. The submuscular group underwent fewer radial releases ( 6.25% vs 33.33%) and less fat grafting (0% vs 10.25%). There was little difference in prevalence of combination cases (31.25% vs 28.2%). Overall, there was a higher rate of capsular contracture in the submuscular group (7.29% vs 0%) with an average grade of 2.13 capsular contracture in the submuscular group. Most of the capsular contractures were unilateral (71.43%). In addition to capsular contracture, lateral malposition was higher in the submuscular group (20.83% vs 2.56%) as well as double bubble deformity (2.08% vs 0%). Complications were also higher in the submuscular group (5.2% vs 0%). The five complications found in the submuscular group included: bilateral implant rupture at 1 year, IMF dehiscence, unilateral infection requiring removal, and 2 cases of wounds requiring revisions. BMI (22.56 vs 23.54) and smoking rates (4.16% vs 5.12%) were similar between groups. Average length of follow up was 754 days in the submuscular group vs 232 days in the subfascial group. Median follow ups were 300 vs 176. The average length to discovery of capsular contracture was 410 days with a median of 120 days. The earliest case of capsular contracture presented at 37 days and as late as 1079 days.

Conclusion: As demonstrated by our findings, subfascial breast augmentation leads to lower rates of capsular contracture, lateral malposition, double bubble deformity, and overall complications. In particular, the decreased rate of capsular contracture in subfascial augmentation contradicts traditional teaching regarding rates of capsular contracture and choice of implant pocket. In addition to creating a more stable pocket in the lateral dimension, subfascial augmentation eliminates the dreaded animation deformity. Overall we have found that the use of a dedicated subfascial pocket allowing precise pocket control is highly effective in creating a stable, safe breast augmentation.