Key points
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The subpectoral pocket can be dissected through the submammary, areolar or axillary incisions and each of these approaches is different.
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The submuscular dissection includes the pectoralis major and the serratus anterior muscles.
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The muscles are transected at the submammary area to avoid implant displacement.
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Textured silicone implants have now been used routinely for 15 years.
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The superior breast mound is not visible with subpectoral breast implants.
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The implant is more protected when it is covered by the muscles and rippling is not visible with the subpectoral implants.
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Breast lumps diagnostics and treatment are facilitated when the implant is placed subpectorally and capsular contracture is less frequent.
Introduction
The subglandular technique described in numerous papers and books has been widely used worldwide for the last 45 years. The subpectoral approach is only used by some surgeons and has received less attention in the international literature. This paper will, therefore, expand mainly on the subpectoral technique.
Patient selection
There are three usual pockets used for breast implants and the election depends on several factors:
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The surgeon studies the thickness of the skin and muscles and the size of the implant the patient wishes to have in relation to her thoracic width.
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The patient’s opinion as to whether she would like a visible superior breast mound is explored during interrogation. If she does, then I consider placing the implant subglandularly but if she refuses, then the submuscular technique is chosen.
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It is also important to educate young patients regarding the future possibility of having parenchyma pathology like fibroadenomas, cysts or breast cancer.
In cases where the subglandular approach is chosen, the implant will attach to the parenchyma. In future mammograms, the parenchyma will be more difficult to study and in case of a tumor or a cyst, biopsies or puntions into the breast will be dangerous. In cases where the implant is submuscular, the parenchyma is more visible in mammograms and biopsies and puntions can be done in a safer way. If the implant is retropectoral, in cases of a quadrantectomy or mastectomy, the parenchyma can be removed while the implant is kept safely under the muscle. My personal preference is to use the subpectoral and the subglandular approaches. There are surgeons who prefer the subfascial approach rather than the submuscular one and this is a third possibility.
Indications
Submuscular implants are indicated when:
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patients have small breasts, thin skin and subcutaneous tissue where the implant will be covered in its superior part, by the thin skin.
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the patient has a history of multiple fibroadenomas or family history of breast cancer.
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the patient has submammary breast implants with capsular contracture.
Submuscular implants are not indicated:
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when the patient has a thick subcutaneous layer or a flat breast parenchyma.
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in competitive sport players.
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where bigger implants than the submuscular dimensions have to be used.
Pre-operative preparation
At home, the patient has to scrub the pectoral and axillary areas with iodopovidone and before the markings are made, the skin is defatted with alcohol. With the patient in a standing position, breast symmetry, submammary crease and areola positions are studied in relation to the size of the implant. The new submammary position, 2 cm beyond the implant limits and the extension of the pocket are penciled onto the skin.
Technique
With the patient under deep sedation, I prepare an anesthetic solution with 25 mL lidocaine 2%, 25 mL bupivacaine 0.5%, 1 mL epinephrine 1 : 1000 and 450–550 mL saline solution. The infiltration is performed touching the external aspect of the sixth rib and injecting the anesthesia in an radial way in order to facilitate the subpectoral and serratus anterior dissection. The infiltration continues at the medial part of the breast, at the border with the sternum where the cutaneous branch of the intercostal nerves emerges and at the lateral emergence of the lateral cutaneous nerves. I also introduce the needle into the inferior border of each rib, blocking the third, fourth, fifth and sixth intercostal nerves, adding extra anesthesia and also producing vasoconstriction at the intercostal arteries and veins. In cases where the approach is axillary, the anesthesia is complemented with an infiltration under the incision lines, at the subcutaneous tissue, all the area to be dissected and in the path to the subpectoral space. In the peri-areolar approach, under the incision line, I infiltrate the parenchyma and the submammary space. With the submammary technique, I also infiltrate under the incision line, at the submammary space and at the submuscular plane.
In the axillary approach, the incision is marked in one of the axillary creases. Then 5 cm subcutaneous is dissected downwards and, with the index finger, I try to determine the pectoralis major muscle and to enter through its posterior aspect ( Figure 3.1 ). In the submammary technique, the incision is made 1 cm above the new submammary fold and at the lateral half of the gland. The pectoralis major muscle is divided obliquely along and separating 5–7 cm of its fibers all along their course first touching and dissecting over the external aspect of a rib, this way avoiding dissecting the intercostal muscles ( Figure 3.2 ). If the areolar approach is used, the incision of preference is at the inferior half of the areola but in cases where there is a small areola, a round periareolar incision brings a wide tunnel for the dissection and introduction of the implant. The parenchyma is divided and the submammary space is dissected obliquely making only a small space for the dissection of the pectoralis major muscle which is carried out in the same way as in the submammary approach ( Figure 3.3 ).
The submuscular pocket dissection differs according to the approach selected. In the axillary approach, the finger tip dissects the pocket beginning from the superior part where the muscle is detached from the thoracic wall. The index finger releases the insertion of the muscle at the costal surfaces then separates the serratus anterior insertion from the ribs using the finger tip with the nail detaching the muscle from the external aspect of the ribs making tunnels and then connecting these two to three tunnels. This dissection continues laterally until the finger tip feels strings emerging perpendicularly from the thoracic wall. These are the lateral intercostal perforator nerves. Finally, I disrupt the long muscle fibers that are usually present more medially by trespassing the SMF. In the dissection of the pocket from the axilla, sometimes the length of my finger is shorter than the extent of the planned pocket so it is necessary to use a dissector as a prolongation of my finger tip ( Figures 3.4–3.6 ).
