Complete implant muscle coverage is shown at left with intact muscle fascia supporting the lower pole of the implant. This support fascia is the extension of the muscle envelope from the pectoralis muscles to the abdominal rectus muscles, and the finger shaped serratus anterior muscles to the sides, and is a stout collagen sheet which stretches slowly after implant placement, but provides reliable long-term internal bra-like support to prevent “bottoming-out”. With this approach the implants are totally behind the breast. Complete muscle coverage of the implant, without cutting through the muscles, can only be achieved by trans-axillary approach, entering the space under the muscle where it lies closest to the skin in the anterior axillary fold. The Advantages of this approach are ease of placement, natural breast shape no implant visibility, no rippling of the implant surface (except textured implants in thin women), lower capsule contracture risk, since the breasts are completely separated from the implant, and no ducts with germs are damaged while placing the implants, low mammography interference, good internal support, and no scars on the breast. Disadvantages are the difficulty mastering the procedure, thus it is not available from all surgeons, muscle discomfort post-op, and implants which tend early to be a bit full superiorly, until the support fascia stretches. This is my preferred technique for the majority of patients.
