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Total Submuscular Placement of Breast Implants

Claude Crockett M.D., F.A.C.S.   05-09-2004

It was in the silicone gel days that accidentally I found myself under the pectoralis. It was in the first 10 or so cases. I  used an areolar approach as I do 99.9% now. I think the term periareolar is a misnomer.

As I was dissecting in the subglandular plane the border of the pectoralis major came up easily and I found the dissection plane to be easy. I did the same on the other side and that was my first total subpectoral implant. I reasoned that possibly the lateral muscle [serratus]  might give further coverage and the technique gradually evolved.

I make the small areolar incision just barely within the areola, use a cutting cautery, teflon covered so tissue won't stick with a smoke evacuator. Making a narrow tunnel thru the breast tissue to the prepectoral fascia, open the fascia over the 5th rib in the mid clavicular line, use a tonsil clamp to  pry the fibers apart over the rib, retract anteriorly with an army-navy, making sure to be under the muscle.

There is that filmy areolar tissue my nurse calls "never-never land" then totally blunt dissection creates the pocket. A Padgett breast dissector is helpful, they come in a small and larger size. Make sure the fascia is left down and a rolling motion with the fingertip is helpful. I always tell the girls they will look "top-heavy " the next day. I have learned by experience where to put the crease depending on the size of the implant.

The rectus and ext oblique fascia is not supposed to be elevated. If it is raised by mistake then some banding can occur transversely along the bottom of the implant. I had this happen early on.

The breast dissector from Padgett Instruments is a handle, 5 or 6 mm shaft and resembles a small flat paddle. Once under the pectoralis,  make sure all fibers are elevated. Sometimes some high inserting strands are persistent. The dissector laid flat on the chest wall can be swept down and the pectoral and serratus fibers come up nicely. It also will not raise the fascia. That should stay down.

I use the Inamed smooth [style 68] in most all but smokers. The valve should be exactly under the nipple. If it is the breast will look great. I always tell them that it will take varying amounts of time to stretch up and accommodate the inframammary plane in the submuscular position. I do 98% this way.

The double bubble has not been a problem since  I quit putting them subglandular. In ptotic ones I can usually get by without a mastopexy. However,  if they have a constricted deformity I do a subglandular dissection, relaxing the breast tissue with the cautery.

This total submuscular technique really works. Zero rippling and zero contracture. I look forward to seeing you. Perhaps I will be able to come to the meeting and present this technique next year in 2005. Claude Crockett, M.D.

 

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The American Society of Cosmetic Breast Surgery 2017    Last modified: June 23, 2017