Background Simultaneous association of the axillary approach (AA) with the subfascial pocket (SF) has been proposed for breast augmentation (BA) surgery. New silicone implant technology and recent improvements in autologous fat grafting (AFG) have ushered in a new era for BA. Objectives This study presents the combined subfascial ergonomic axillary hybrid (SEAH) method and evaluates its aesthetic benefits after primary/secondary BA. Methods 42 patients (84 breasts) underwent BA with the SEAH technique; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant. Results Mean patient age was 34.6 years (range: 28–56), mean body mass index was 18.8 kg/m 2 (14.4–26.1). The most common implant (SmoothSilk surface Ergonomix style) volume was 255 cc (175–355), patients received a mean volume of 96 cc of fat (60–145)/breast in the subcutaneous tissue. Average lower pole stretch value was 40.5% (21.75 mm) and 13.1% (9.9 mm) for preoperative to 10 days post-procedure and 10 days to 18 months post-procedure respectively. Postoperative complications included subcutaneous banding in the axilla [n = 3 (7.1%)], small wound dehiscence [n = 1 (2.3%)], and hypertrophic scarring [n = 1 (2.3%)]. No rippling, implant malposition, infection, or fat necrosis was observed during a mean follow-up of 18 months (6–32). Conclusions SEAH is a useful and versatile technique combining the benefits of AFG and implant-based augmentation, particularly with regard to soft-tissue coverage, and avoids the limitations of the submuscular position. The combination of ergonomic gel implants and a SF pocket can yield satisfactory aesthetic outcomes.

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Background: Autologous fat grafting is a procedure indicated for breast augmentation to improve coverage of silicone implants and redesign breast shape. Different techniques are based on parameters that have not been systematically standardized. The authors present a method using breast zone standardization based on breast anatomy to achieve an anatomical composite breast. Methods: The authors performed this zone standardization in 76 breasts (38 patients) undergoing primary/secondary augmentation. The area between the implant and the clavicle and parasternal area was marked to receive fat grafting and divided into three zones. A mathematical formula [volume of autologous fat graft = (π × r2 × p)/4.8] was used to estimate the fat graft volume according to implant volume in the respective zones. Results: Implant volumes ranged from 205 to 375 cc (mean, 265 cc), and patients received an average fat graft volume of 105.3 cc per breast (range, 36 to 135 cc); the average fat volume in zones I/II and III was 78.28 cc (range, 0 to 100 cc) and 27.03 cc (range, 15 to 60 cc), respectively. Three minor complications were observed (5.2 percent) during a mean follow-up of 12.8 months. A high correlation was observed between the fat grafting performed in the cohort and predictions obtained from the formula (p < 0.001). Conclusions: Recognizing risky cleavage breast zones between the implant pocket and the upper and medial quadrants remains essential to attain satisfactory outcomes. Although experience and proper judgment are still important in the fat grafting technique, the data presented here offer plastic surgeons an additional standardized framework to help deliver predictable hybrid breast augmentation.  CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Summary: Advances in breast augmentation techniques have led to safety improvements and better aesthetic results. The concurrent combination of the axillary approach with a subfascial pocket has been suggested for augmentation procedures, because it avoids breast scarring and the limitations of submuscular positioning represented by breast animation when the pectoral muscle is contracted. With the improvement of autogenous fat grafting techniques, new implant coverage options and more natural results have been proposed with more superficial implant pockets; simultaneous autogenous fat grafting with silicone implants (defined as hybrid breast augmentation) has recently been evaluated as a promising technique. Combining these two procedures allows core volume projection and natural cleavage while camouflaging implant edges. Fat grafting is also useful in reducing intermammary distance and achieving a smaller and smoother transition between the breasts. This article and the accompanying videos provide a detailed, step-by-step guide to hybrid breast augmentation using a subfascial axillary approach, with a predictable and optimized surgical outcome.

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Background: Augmentation mastopexy (AM) is a challenging procedure. Complications include implant displacement and visibility, which can be addressed, but the stability of the smooth implant surface and poor soft-tissue coverage may present limitations. This article describes a surgical technique for AM using a composite reverse inferior muscle sling associated with autogenous fat grafting. Methods: Forty-five patients (90 breasts; mean age, 37.7 ± 7.2 years) underwent hybrid composite reverse inferior muscular sling AM. An upper/medial pole area between the implant and the clavicle region and parasternal area was marked to receive fat grafting and divided into three zones. Three-dimensional imaging was used to evaluate lower pole stretch and intermammary distance. Results: The average implant volume was 265 cc (range, 175 to 335 cc). The average fat volumes in zones I/II and III were 80.1 (range, 61.6 to 95.2 cc) and 39.3 (range, 25.2 to 47.3 cc), respectively. Five complications were observed in three patients (6.6%)—minor dehiscence in two (4.4%) and nipple-areola asymmetry in one (2.2%). The lower pole stretched 11.51% (9.9 mm) and 9.8% (8.5 mm) on the right and left sides, respectively (P < 0.0001), between 10 days and 1 year postoperatively. The intermammary distance was reduced, on average, 49.9% (25.1 mm) (P < 0.001) between the preoperative value and 1 year postoperatively. Conclusions: Hybrid composite reverse inferior muscular sling has led to improved aesthetic results for patients with breast ptosis and poor tissue coverage. Fat grafting and recognizing cleavage zones are still important to obtain satisfactory results. This procedure offers a good alternative for AM candidates, providing an adequate smooth surface for implant stabilization.

Summary: Reoperative procedures after breast augmentation are frequently more complex than primary cases because of local complications and insufficient soft-tissue coverage. Although the transaxillary incision is often indicated in primary breast augmentation, limitations of this approach include secondary surgery and correcting complications after using this approach via the same incision. Combining the transaxillary technique with a subfascial pocket has been suggested to avoid breast scarring and the limitations of submuscular pockets represented by breast animation. With advances in autogenous fat grafting (AFG) techniques, implant coverage alternatives and more natural outcomes have been reported from more superficial implant pockets. Simultaneous AFG with silicone implants (defined as hybrid breast augmentation) has been evaluated recently as an attractive procedure. These two techniques combine to provide breast projection and natural cleavage while camouflaging implant edges. AFG is also important to reduce the intermammary distance and achieve a smoother transition between the breasts. The transaxillary approach can be useful in reoperative breast augmentation and avoids additional scarring on the breast. This article and the accompanying videos provide a detailed, step-by-step guide to reoperative hybrid breast augmentation using a subfascial transaxillary approach, with a predictable and optimized surgical outcome.