At the cellular level, BTP focuses not only on minimizing trauma but also on actively preserving the biological integrity of native breast tissue by modulating the foreign body response (FBR) during and after surgery. Together, the BTP surgical approach and the selection of implants with a low-inflammatory surface topography foster an environment that facilitates the formation of a stable tissue envelope composed of preserved ligament structures and a low-fibrotic, uniform periprosthetic capsule. This, in turn, contributes to lasting tissue softness and reliable implant integration.

Regarding implant surface topography, research has shown that implants with a 4-micron surface elicit the lowest inflammatory response when compared to traditional smooth, microtextured, and macrotextured surfaces ( Fig. 1 ). This topography was specifically designed to enhance biocompatibility and minimize tissue disruption by suppressing the FBR and fibrosis by the presence of higher levels of immunosuppressive FOXP3 + regulatory T cells.

Composition of immune infiltrate in capsules surrounding conventional smooth and 4-micron surface implants. ∗∗∗ P >.001.

( Adapted from Doloff JC, Veiseh O, de Mezerville R, Sforza M, Perry TA, Haupt J, et al. The surface topography of silicone breast implants mediates the foreign body response in mice, rabbits and humans. Nature Biomedical Engineering. 2018;2(12):914–928. https://doi.org/10.1038/s41551-018-0280-9 .)

This unique behavior matches the clinical evidence with low capsular contracture rates regardless of implant placement behind or above the pectoralis major muscle (PMM), exemplifying the first level of tissue preservation by establishing a biologically stable interface that supports implant softness and integration over time.

At the structural level, BTP emphasizes preserving the breast’s native anatomic framework. This approach respects the integrity of the fascial and ligamentous networks, which play a critical role in maintaining long-term stability and optimal implant positioning.

The posterior extensions of Cooper’s ligaments connect with the circummammary ligament (CML), a dense fibrous ring that surrounds the corpus mammae and provides structural support along its perimeter. This ligamentous ring anchors the breast to the chest wall and delineates a natural boundary between the superficial and deep fascial layers, thereby preserving vascular and lymphatic integrity and facilitating the even distribution of mechanical forces across the breast and chest wall ( Fig. 2 ).

3D rendering illustrating the CML delineating the boundary of the breast, with Cooper’s ligaments as a supportive structural network.

( From Establishment Labs; with permission.)

In addition, placing the implant in a prepectoral pocket preserves the PMM, helping to maintain the chest and upper arm function while minimizing the risk of complications such as animation deformity.

Despite the 4-micron implant surface not promoting tissue ingrowth and the use of a prepectoral placement, a prospective 100-patient IRB-approved study of breast enhancement using a BTP technique reported a 0% incidence of inferior malposition rates at 3 years. This underscores the significance of preserving the breast’s supportive structures and leveraging the precision of the BTP tools and methods.

Whereas the structural level defines the breast’s anatomic footprint, the dynamic level relates to its spatial projection and behavior in motion, represented through Preexisting Breast Volume and Projection. These parameters shape how the breast appears in profile and frontal view, responds to gravity and movement, and maintains a natural aesthetic. Understanding this dynamic level requires more than measuring overall volume; it requires understanding breast volume distribution (BVD).

To assess and plan augmentation dynamically, the BTP approach uses the concept of Breast Topography, a mapping system that visualizes BVD across the thorax. This tool identifies natural areas of prominence and deficiency, enabling precise implant placement within the preserved tissue envelope. A key landmark within this mapping is the M Line , a horizontal line positioned 1–1.5 cm above the superior border of the areola. This line represents the apparent transition zone between the chest wall and the projecting breast mound, serving both as a surgical reference point and a communication aid for patient consultations. Integrated into the breast topography system ( Fig. 3 ), the M line helps clarify that, in most patients, the primary volumetric deficiency is located in the upper pole, making it the first target for augmentation.

Crisalix preoperative assessment, Breast Topography enabled. The image highlights areas of natural volumetric prominence and deficiency. The M line —a dotted line between the purple indicators.

The second objective is to enhance medial cleavage, which is often compromised by lateral breast orientation, the natural slope of the thoracic cage, or low native volume. By simultaneously addressing upper pole restoration and medial projection, BTP achieves optimal aesthetic outcomes using minimal implant volume, preserving tissue quality while enhancing shape. The outcome of this dynamic concept is a lighter breast that is proportionate, stable with natural movement, and organically contoured, rather than heavy or overfilled with unnecessary breast implant volume.

The functional level of BTP focuses on preserving key physiologic systems essential to postoperative quality of life, including somatosensory innervation, musculoskeletal integrity, and the ability to resume daily activities without impairment.

Sensory preservation

Sensory integrity, particularly of the nipple areola complex (NAC), is a fundamental component of functional breast surgery. BTP techniques prioritize the protection of the fourth and fifth anterior intercostal nerve branches, which are primarily responsible for afferent innervation in this region. ^, Incision placement along the inframammary fold (IMF), especially when slightly lateralized to the 5 and 7 o’clock positions, plays a significant role in protecting these nerves ( Fig. 4 A and B ). Additionally, by adhering closely to native anatomic planes and avoiding thermal dissection, BTP reduces the risk of sensory compromise. Clinical follow-up data report no loss of NAC sensation, reinforcing the neuroprotective potential of this approach and underscoring its relevance to both functional outcomes and psychosocial well-being.

( A and B ) Lateralization of the IMF incision, preserving the NAC sensation through protection of the 5th anterior intercostal nerve. Anatomic ( A ) and graphical ( B ), with magnified view, illustrate the 5 and 7 o’clock positions.

( From Establishment Labs; with permission.)

Tunneling is a minimally invasive technique used to access the implant pocket through a narrow anatomic corridor, typically originating from either the axillary crease or the IMF. A 2 cm diameter tunnel is created with a specialized instrument with a tip that navigates atraumatically and precisely through the CML at 1 cm above the PMM fascia, and toward the posterior aspect of the breast gland. This space is located directly behind the pseudocapsule of the corpus mammae and within the posterior lamellar fat of the superficial fascia ( [CR] ). ^,

Importantly, this trajectory respects the boundaries of the CML and preserves both Cooper’s ligaments and deep fascial layers. This preservation enables controlled, consistent tunneling through tissue planes, facilitating precise medial and lateral pocket definition while minimizing mechanical trauma.

Following tunneling, an inflatable balloon (IB) with an integrated handle to support controlled expansion is introduced deflated and then incrementally inflated to achieve mechanical elongation of tissue planes and hemostasis, rather than disruption by blunt or sharp dissection. This system allows for radial expansion that respects the fascial and ligamentous architecture of the breast ( [CR] ). The diameter and geometry of this balloon create a 3D space with equivalent dimensions to the implant that will be subsequently placed for a tight, controlled pocket within the boundaries of the CML. This approach contrasts with pocket creation using electrocautery, which may lead to complications such as devitalization of breast tissue, disruption of sensory nerves causing pain, inadequate hemostasis, and thermal tissue damage to skin flaps. Additionally, pocket creation using diathermia or manual techniques is highly dependent on the surgeon’s skills and patient tissue characteristics, often resulting in unprecise and uncontrolled pocket dissection.

This controlled balloon elongation technique preserves neurovascular integrity and prevents over-dissection, supporting long-term implant stability and sensory function. The resulting pocket enables natural implant movement within a preserved tissue matrix, promoting dynamic nesting, sustained softness, and predictable positioning through reinforced fibroglandular support and parenchymal enclosure.