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The authors prefer subfascial plane implants to submuscular ones. Possible rotation of anatomic implants and the subsequent asymmetry when contracting the pectoral muscle are avoided. Pectoral muscle is not detached from its insertions, resulting in less postoperative pain. Likewise, the authors prefer a subfascial to subglandular pocket since the weight of the subglandular pocket and the glandular weight itself are borne by the skin envelope leading to breast ptosis development over time. On the other hand, fascia provides additional support to the subfascial implant, thus eliminating ptosis development and achieving good filling of the upper pole similar to the filling provided by subglandular implants.

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We present the surgical technique for mammary reconstruction using tissue expander with endoscopic approach, associated to partial detachment of the pectoralis muscle at the fourth rib and complete or nearly complete intraoperative expansion. Tissue expansion for breast reconstruction is a well-honored technique that provides satisfying esthetic outcomes, with minimal morbidity for the patient. Nevertheless, this technique has some potential problems: (1) wound dehiscence with extrusion of the expander; (2) the patient discomfort during the expansion process (weekly visits for the refill of the expander); (3) the poor definition of the lower pole of the breast and cranial migration of the expander with excessive roundness of the upper pole. By using intraoperative tissue expansion, these drawbacks can be avoided. We report herein our experience with this technique in 53 consecutive patients (56 breasts) undergoing a secondary breast reconstruction since December 2001.

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