Commentary On: Subfascial Ergonomic Axillary Hybrid (SEAH) Breast Augmentation: A Surgical Approach Combining the Advantages of Incision, Pocket, Silicone Gel, and Fat Grafting in Primary and Revision Breast Augmentation Surgery

The transaxillary approach to breast augmentation has been shown to be an effective technique that can achieve outcomes comparable to those seen with the more popular inframammary approach.¹ Improved outcomes with more current approaches to transaxillary breast augmentation, in both partial subpectoral and subfascial planes, are the result of the use of endoscopic assistance or specialized lighted retractors, each of which allows for optimal tissue visualization and technical control when creating the tissue pocket.^2-5 In their large consecutive patient series, Huang et al showed that the added visualization afforded by the endoscopic approach resulted in significantly fewer reoperations and malpositions when compared with their nonendoscopic group, with no significant differences in hematoma or contracture.⁶ It is also important to note that patient satisfaction following transaxillary breast augmentation has also been shown to be superior to that seen with the inframammary approach.^1,7

The axillary hybrid approach described in this paper⁸ is based on the combination of creating a subfascial pocket and adding fat in a plane superficial to the implant following device placement. Direct visualization of the perforator vessels is possible through the use of specialized lighted retractors in place of endoscopy. The authors describe a tissue-based system of patient selection: the criterion is an upper pole pinch thickness of less than 2 cm, producing a patient group that would otherwise not be candidates for a subfascial technique. They suggest that their hybrid approach is not needed in patients with pinch thickness measurements of 3 to 4 cm, with such patients being excluded from the study group. Reported complications were minimal, and included subcutaneous axillary bands (3 patients, 7.1%), small wound issues (1 patient, 2.3 %) and hypertrophic scarring (1 patient, 2.3%). Contracture was seen in 1 patient following hematoma (1.7%). The authors reported no patients with rippling, implant malposition, fat necrosis, or fat grafting donor site complications.

The subfascial approach to transaxillary breast augmentation has been popularized by multiple authors, with the technique for pocket creation used in this series most directly following that described by Graf et al.^9,10 The anatomy of the prepectoral fascia is very familiar to surgeons who perform transaxillary breast augmentation, because the layer has its greatest thickness in the area adjacent to the axillary incision. Creation of a subfascial pocket is possible from all incisions, with the understanding that the layer is less distinct in the lower pole of the breast, leading to controversy relative to the value of the fascial layer. The dissection plane is immediately superficial to the pectoralis major muscle itself. As emphasized by the authors, this approach has the appeal of avoiding muscle animation effects that can be seen with a partial subpectoral approach, and has, as an isolated technique, been associated with a faster postoperative recovery.

As compared with subglandular placement, it has been suggested that the subfascial plane can minimize implant edge prominence due to the preservation of the additional layer over the implant.⁹ In their series of 263 patients, most of whom had axillary access incisions with all implants placed in a subfascial plane, Graf et al reported no implant animation and no implant edge visibility. This is a remarkable finding in that all patients underwent augmentation with Allergan (Irvine, CA) Style 410 FM implants—macrotextured, shaped, highly cohesive silicone gel devices that might be assumed to perhaps have a higher risk of edge visibility given the Cohesive III gel and macrotextured shell. In a recent paper on revision implant surgery by the transaxillary approach, the author of this series also suggests the fascial layer is of value in minimizing the appearance of the implant limit.³ It is important to note that, in this series, the authors acknowledge that their selection criteria to add fat in the hybrid technique described is to address the suboptimal tissue cover seen in patients with an upper pole pinch thickness of 2 cm or less. This is a central aspect of the rationale for combining fat grafting with subfascial augmentation in this series.

Another important issue relative to the hybrid technique outlined in this series is the use of the newest generations of breast implant technology, specifically the Motiva (Houston, TX) Ergonomix devices. They are reported by the authors and the manufacturer to offer higher viscoelastic properties with 100% gel fill. The ergonomic gel is reported by the authors to have a low viscosity with much higher elasticity, shifting the maximum projection point to the lower pole of the breast when the patient is standing. The authors correctly advocate that great care be given to creating an implant pocket that matches the implant dimensions exactly, given that the Ergonomix surface will have no tissue ingrowth. The authors suggest that their series showed that a 6-month period was needed to establish a stable lower pole stretch measurement. This is why patient satisfaction was measured at this time point.

The potential advantages of the latest generations of breast implants, in the context of recent refinements of technique, is also a point of emphasis by Lista et al, who showed that contracture rates with subglandular placement of the latest generations of Mentor (Santa Barbara, CA) and Allergan smooth-wall silicone gel devices were equivalent to those previously seen with textured devices.¹⁰ Likewise, this series also shows a very low contracture with prepectoral placement of the Motiva Ergonomix devices. Other than a low contracture rate, however, one can question whether a hybrid approach that places fat anterior to a breast implant is the optimal situation to accurately assess the value and effectiveness of any breast implant technology. It might be suggested that the implant technology may be best evaluated, in terms of their specific material and design properties, by subfascial use in patients with upper pole pinch thickness measurements of 2 cm, without the added tissue cover provided by fat grafting.

The addition of fat to breast augmentation is not new, and has been described by multiple authors, most notably Auclair et al.^12,13 In this series, an average of 380 mL was harvested from each patient, combining fat from multiple donor sites including the lateral and medial thighs, flank, abdomen, and inner knee areas. The authors report that the average BMI was 18.8 kg/m², but that a majority (88%) were normal or overweight with adequate quantities of fat to harvest from the abdominal wall. They reported that 5 patients (12%) had BMI < 18 kg/m², with severely limited donor fat available in the abdominal wall area. Although they advocate taking great care in selection of fat harvest donor areas and suggest small amounts of fat be taken from multiple areas, they report that there were no donor deformities created from fat harvest.

As for the injections themselves, the authors suggest that fat should be injected following implant placement, with the patient in the sitting position. Emphasis is on the upper pole and cleavage areas, with routine fat insertion of one-quarter to one-third of the implant volume to these areas, with variation depending upon implant projection and quality of soft tissue coverage. Although all would agree that these areas would most likely have the most importance when adding fat, some might argue that this approach is addressing limitations in the properties of the implant used when used as a primary procedure. Additionally, it would seem that the upper pole and cleavage areas might be best addressed by making periareolar access incisions to avoid occasional scarring that can result from access incisions located above the augmented breast. They contrast their approach with that of Auclair and co-workers, who advocate a closer match of fat volume to implant volume to allow for more complete diffuse coverage of the anterior augmented breast area with fat.^12,13 Complications reported relative to fat grafting include oil cysts in 5.1% of breasts and microcalcifications in 12% of breasts. The authors propose that an ideal shape is achieved by injecting fat in the upper pole to give a round implant anatomic shape in the upper pole. Patients in the series received an average of 96 mL of processed fat per side, combined with an average implant volume of 255 cc.

The authors should be commended for their expertise in transaxillary breast augmentation and for their most recent combination of techniques that make up their SEAH approach to breast augmentation. The outcomes from the combination of subfascial placement of the ergonomic gel implant with fat grafting anteriorly were consistent with minimal complications. Careful consideration of this hybrid approach, however, would suggest that the addition of fat anterior to the ergonomic gel device likely removes most of the ability to make meaningful assessments of the breast implant device technology. It is also important to note that a hybrid approach such as that presented in this series will likely increase in importance as shaped highly cohesive gel implants with a textured surface are used less due to concern with potential side effects that appear to be unique to textured devices. Additionally, the use of this hybrid approach may be preferred over time to lessen dependence on the implant device and provide autologous tissue to make the result function in a more natural way over time. The approach used in this series was based on the selection criterion of an upper pole pinch thickness of 2 cm or less, with fat grafting otherwise not warranted. The authors’ hybrid approach seeks to make patients who are not typically appropriate candidates for subfascial placement into candidates by the addition of fat. The approach of the authors assumes that the issue of animation, which can be seen following partial subpectoral augmentation, is more harmful to patient outcomes on a widespread basis, as compared with the more complicated hybrid approach of fat grafting and subfascial placement in patients with otherwise inadequate tissue cover. The hybrid approach, however, accepts the inherent disadvantages of prolonged operating time, longer periods of activity restriction and recovery, and risk of fat donor site harvest contour irregularities otherwise not seen with partial subpectoral approaches. Despite these issues, the authors have impressive experience and offer a unique combination of nuances that significantly advances the versatility of the transaxillary approach to breast augmentation.

Disclosures

Dr Strock is a consultant for Mentor Worldwide (Johnson & Johnson, New Brunswick, NJ). The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.

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