The transaxillary approach to breast augmentation is a well-established procedure with pleasing results. Its main advantage is that the scar is distant from the breast and well concealed. I offer patients both the periareolar and transaxillary approaches for breast augmentation. Ninety-six percent of my patients choose placement through the axillae because the scar will be hidden and the gland is not surgically altered.

The standard procedure for transaxillary breast augmentation is submuscular implant placement; aesthetic results are usually very satisfactory. However, submuscular placement may become obvious when pectoral muscle contraction distorts the breast, especially during exercise. The pectoralis muscle, whether the approach is periareolar or transaxillary, can flatten the submuscular implant and displace it laterally. To prevent this distortion, patients avoid certain exercises and may ultimately seek alternative implant positions.In extreme cases, the breast can demonstrate a tear trough deformity, along the lower lateral edge of the pectoralis major muscle, that is more evident with muscular activity.

Subglandular implant placement through the axilla is more natural-looking but is difficult to perform. The plane of dissection is not easy because the path is initially subcutaneous. Furthermore, upper-edge visibility or rippling of the implant can also be a problem, especially in thin patients.

In a recent paper, Graf et al reported 8 subfascial augmentations, describing how the dissection should be performed. Here I present my experience using an intermediate plane under the pectoralis fascia. I have performed 16 breast augmentations inserting silicone gel–filled, textured implants with this technique.

Subfascial breast augmentation provides consistent, satisfactory results. The surgical technique is straightforward, and, compared with submuscular placement, there is less risk of hematoma (bloodless field), less pain, and faster recovery.

Cadaver dissections

Cadaver dissections were used to explore the feasibility and level of ease of dissection under the pectoralis fascia. Six breasts in 3 cadavers were dissected. First, transaxillary subfascial dissection was completed as in a clinical breast augmentation.

After dissection, I raised a flap from lateral to medial that included the breast, following the limits of the pocket, to check the plane of dissection and the integrity of the fascia. The pectoralis fascia remained attached to the skin side of the dissection in all cadavers. In all the cadaver dissections, the pectoral subfascial plane was not in continuity with the rectus abdominus and external oblique subfascial plane. Release of the pectoral fascia from the rectus abdominus and external oblique fascia above the level of the inframammary fold ensures that the implant will be covered by pectoralis fascia in its upper two-thirds and subglandular in its lower one-third . Laterally, the implant is also covered by fascia .