A modified subfascial breast augmentation, called Cold-Subfascial Breast Augmentation, avoids negative cosmetic effects from muscular animation, motion and shape change caused by arm motions and lateral displacement, or bottoming out caused by pectoral activation, says Miami, Fla., based plastic surgeon Rian A. Maercks, M.D., who owns the trademark on the procedure.
What’s different? Dr. Maercks tells The Aesthetic Channel that he doesn’t use electrocautery or blunt dissection.
“The pectoral fascia is a very thin layer, and it’s strong if it’s kept intact. But if you use blunt dissection, you can delaminate the structure. And if you use electrocautery, you vaporize much of it and cause apoptosis, or programed tissue death,” he says.
Dr. Maercks has modified subfascial breast augmentation, by using only cold technique — a scalpel or sharp scissors.
“By directly visualizing the dissection and doing a sharp dissection, I’m able to divide the muscular-fascial interface, preserving all the fascia,” he says. “Because it’s preserved, I have structural support to not only support the breast, to help prevent bottoming out from lateral displacement, but also to shape the breast.”
Dr. Maercks performs the procedure by accessing the interface of the pectoral fascia and pectoralis major muscle through the axilla. After careful dissection of the fascia from the muscle, he places the implant under the fascia, above the muscle.
Dr. Maercks says he uses the fascia to mold the breast in a more tear-drop shape.
With the Cold-subfascial approach, if Dr. Maercks uses a low-fill round implant, he gets an anatomic-shape just as he would using an anatomic implant.
“So, the fascia participates a lot in the shaping and the aesthetic outcome of the breast,” the plastic surgeon says.
Anyone who is a good candidate for breast augmentation, would be a candidate for the Cold-subfascial approach, according to Dr. Maercks.
“It’s a common thought that you cannot use the subfascial approach with very thin women, who have a low upper breast pinch test. But it works very well in these patients. The fascia helps shape the implant into an anatomic shape and also helps redistribute the breast tissue,” Dr. Maercks says.
Dr. Maercks says the largest implant he has placed doing this procedure is a 685 cc, and while he doesn’t believe there are limitations to how big an implant can be used, he doesn’t have experience using larger implants with the technique.
There’s definitely a learning curve for optimally performing the Cold-Subfascial Breast Augmentation, he says.
“When you’re starting, you really have to take your time. Technically it’s very different than what people are used to. Be ready to increase your operative time the first few times you do it, and really get a feel for what you can do and what you can’t do,” he says.
For best results, Dr. Maercks, who has been performing the Cold-Subfascial Breast Augmentation for more than seven years and has performed more than 100 such procedures, recommends that surgeons are meticulous with the fascial resected tissue, to keep it protected.
Another trick is to always do lateral dissection first.
“If you do medial resection first, then doing the lateral dissection can become very difficult,” he says.
Additionally, he says, be conservative on the lateral dissection.
“It’s easy to over-dissect laterally, and there’s not much you can do to fix that once it happens. If you over-resect laterally, you’ll lose the advantage of the fascial support that helps to hold up the breast and prevents it from falling,” Dr. Maercks says. “You can always dissect more.”
Another Point of View
Michael S. Kluska, D.O., president of the American Academy of Cosmetic Surgery and medical director of The Greenbrier Center for Cosmetic Surgery and MedSpa in White Sulphur Springs, W.V., says there are many ways to perform breast augmentation and all have their pros and cons.
“The subfascial approach has been around for quite some time and used by a small percentage of physicians across the country,” Dr. Kluska tells The Aesthetic Channel. “This approach is indeed a good way to shape the breast in patients wanting small to moderate breast enlargement. Also, the subfascial approach offers another tool in the armamentarium for the surgeon to aesthetically address the breast.”
Dr. Kluska doesn’t use the subfascial approach, however.
“There are many factors that contribute to the increased risk for capsular contracture following breast augmentation. One of these factors is postoperative bleeding with possible hematoma formation,” Dr. Kluska says. “Although the subfascial plane is relatively avascular, there are still perforating vessels that could bleed following the elevation — without cautery — of this flap. This could ultimately increase the risk of capsular contracture or hematoma following this approach.”
In addition, many surgeons will pack the wound with some form of surgical sponge, Dr. Kluska says.
“Some feel that fibers from the sponge can also lead to capsular contracture,” he says. “In an approach that does not use electrocautery, packing may be necessary for hemostasis and could further potentiate the risk for capsular contracture.”
Length of time in the operating room is still another reason Dr. Kluska says he doesn’t use the approach.
“Because of the meticulous dissection necessary to elevate the fascia, the procedure takes a bit longer than the standard approach used for breast enhancement surgery. The patient would be subjected to longer surgery and anesthesia times,” he says.