Subfascial Primary Breast Augmentation with Fat Grafting: A Review of 156 Cases

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I agree with the authors1 that the subfascial plane2–4 provides excellent coverage of the implant and avoids using the retromuscular plane preserving the pectoralis major. However, I object to the writers’ contradictory and insufficient justifications provided for their choice of round implants.
The first incongruity in the article is that the authors claimed to have used anatomical implants in 70.52 percent of their patients from December of 2006 until the end of 2013. However, they have resorted to use of these implants in only 9 percent of their cases since 2014. The reasons why they stopped using anatomical implants, if the index of rotation they published within their statistics is 0.64 percent, are not very clear though. Any other factors directly leading to unwanted results postoperatively were not described either.
Second, the pectoral fascia is a structure that allows excellent coverage of the upper pole and also camouflage of the implants borders, whether round or anatomical,5 because the fascia attached to the pectoralis major muscle pulls the muscle and avoids the visibility of the prosthesis edges; for this reason, I question the use of the fat graft, which was placed at the level of the upper pole in 89.7 percent of cases. It is necessary to emphasize that once this technique has been adopted, it is vital to take into account the individual variability of reabsorption, the variables within the same patient with asymmetric reabsorption, and the durability of the fat graft requiring a second fat injection.
Third, the need for decubitus modifications for the removal of adipose tissue, with the consequent contamination of the surgical fields, increases the possibility of infection. Although fat placement is performed in a subcutaneous plane, the minimal inflammation or erythema of the mammary area can result in an infection, with the later removal of the implant. Such a position may also cause a subclinical infection, leading to the formation of a capsular contracture.
Finally, it is worrying that although the fat is reabsorbed over the course of years, which together with the round implants has had a decisive role in the outcome of this practice since 2014, the long-term results will be artificial or require a new operation to place more fat graft.
In my private practice, I have used the subfascial plane for 928 patients from November of 2001 to December of 2016. Our routine is (1) sedation, (2) intercostal and pectoral block with the aid of ultrasound, (3) added to a superwet infiltration of the breast tissue facilitating the lifting of the pectoral fascia in the upper pole and the fascia of the rectus muscle and serrate level of the inferior pole by hydrodissection, and (4) providing total coverage of the implant by the fascia of the mentioned muscles. Since 2009, 70 percent of the implants I have used in primary breast augmentation have been anatomical devices,6,7 bringing us satisfactory results in patients older than 35 years who seek more natural results in implants that are not extremely large.
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