A Modified Dual-plane Technique Using the Serratus Anterior Fascia in Primary Breast Augmentation

Hwang, D. Y., Park, S. H., & Kim, S. W. (2017). A modified dual-plane technique using the serratus anterior fascia in primary breast augmentation. Plastic and Reconstructive Surgery – Global Open, 5(2), Article e1213. https://doi.org/10.1097/GOX.0000000000001213

Introduction Thin soft tissues can make breast implants difficult to conceal, allowing implant edges to become visible or palpable and surface folds to appear as rippling. Achieving a smooth, natural-looking breast contour therefore depends on the relationship between the implant, the available tissue envelope and the design of the surgical pocket.

In their 2017 publication, Dong Yeon Hwang, MD, and colleagues describe an anatomical approach to implant coverage and breast contour in thin patients. Their modified dual-plane technique uses the patient’s own chest wall fascia—serratus anterior fascia, with external oblique fascia where appropriate—to extend coverage over the lower outer implant while preserving lower-pole expansion. The approach combines muscular and fascial coverage to address an area that may be insufficiently concealed in thin patients.

Anatomy The pectoralis major muscle covers the upper and inner portions of an implant placed in a dual-plane pocket. Releasing its inferior attachments allows the lower breast to expand, helping the implant settle into the intended contour. Beyond the muscle’s lower outer border, however, the implant relies more heavily on the overlying breast and subcutaneous tissues for concealment.

The serratus anterior fascia is a connective tissue layer over the serratus anterior muscle along the lateral chest wall. Depending on the patient’s anatomy and the level of access, external oblique fascia may also be available. The authors elevate these layers as a continuous sheet while leaving the underlying muscles intact.

Together, the pectoralis major and elevated fascia form complementary areas of coverage: muscle superiorly and medially, and fascia inferiorly and laterally. During lateral dissection, the authors identify and preserve the lateral cutaneous branch of the fourth intercostal nerve. This makes sensory preservation an important anatomical consideration alongside implant coverage.

Figure 1. Dual-plane breast implant placement. The pectoralis major covers the upper and medial portions of the implant, while release of its inferior attachments permits lower-pole expansion. Conceptual schematic; not to scale.

Patient Consideration The technique was developed for thin patients with small, non-ptotic breasts and limited tissue coverage. The study included 27 patients undergoing primary augmentation between June 2014 and June 2015. Their mean age was 29.4 years and mean body mass index was 18.9 kg/m².

Preoperative pinch-test measurements were less than 2 cm at the upper pole and less than 1 cm at the lower pole and lateral breast. These findings illustrate why direct assessment of the tissue envelope matters: BMI describes body habitus, while the pinch test helps identify where an implant may have insufficient coverage.

The distinction between volume deficiency and breast ptosis is also important. This series concerned small, non-ptotic breasts; it did not evaluate mastopexy or combined augmentation and lifting. Although the authors suggest possible revision applications, the reported clinical outcomes relate to primary augmentation. Implant Selection Matching volume to the tissue envelope Implant selection begins with the relationship between the desired breast volume and the tissues available to cover it. In a thin patient, the implant’s contribution to shape is particularly apparent because the existing breast provides less camouflage. The study’s central contribution is therefore to consider implant volume alongside the design of the surrounding pocket.

The implants used ranged from 255 to 360 mL. Mean volumes were 288.9 mL on the right and 281.6 mL on the left. These measurements describe the study population rather than a standard size range for thin patients. They show the volumes used with this particular coverage technique, but do not establish an optimal implant size.

Additional fascia is intended to improve coverage of an otherwise thin envelope. It should not be interpreted as evidence that larger implants can be accommodated without limit. The paper does not offer a sizing algorithm or compare the effects of different implant volumes on long-term outcomes.

Shape and implant characteristics The authors used anatomical and round textured cohesive gel implants, with anatomical implants shown in their clinical examples. The paper focuses on tissue coverage rather than a comparison of implant designs, so it does not demonstrate an advantage for one shape over another.

Similarly, the study does not provide a selection protocol for implant base width, projection or gel cohesivity. Its implant choices belong to the 2014–2015 treatment period and should be read in that historical context. The reported use of textured devices is not a current implant recommendation.

Accounting for asymmetry

Pre-existing asymmetry may require different implant volumes on each side. In one illustrated case, the authors used 295 mL on the right and 255 mL on the left. This example demonstrates individualised volume selection, although the paper does not describe a formal algorithm for assessing or correcting asymmetry.

Considering implant and pocket together

The modified pocket gives implant selection its anatomical context. Pectoralis major covers the upper inner implant, while the fascial sheet extends coverage over the lower outer portion. The intended result is better concealment of implant edges without the restriction on lower-pole expansion associated with complete muscle coverage. Implant volume and the available tissue envelope remain closely linked.

Technique

Inframammary access

The authors performed all augmentations through an inframammary incision under general anaesthesia. An incision approximately 4–4.5 cm long provided access to the fascia over the underlying chest wall muscle. The muscle encountered was usually serratus anterior and occasionally external oblique, reflecting differences in patient height and chest wall anatomy.

Figure 2. Inframammary incision on the right side of the breast. A, Muscle fascia is exposed; (B) transverse incision is made on its lower border.

Elevation of the fascial layer

The key modification is the elevation of serratus anterior fascia, including external oblique fascia where appropriate. The authors stress the importance of raising the tissue as one continuous sheet. An intact fascial layer can then extend across the lower outer implant rather than leaving this area covered only by the thin breast envelope.

During this dissection, the lateral cutaneous branch of the fourth intercostal nerve is identified and preserved. The serratus anterior and external oblique muscles remain intact beneath the elevated fascia. The technique therefore uses a fascial layer for additional coverage, without harvesting a segment of either muscle.

Figure 3. A, The fascia is elevated in 1 sheet. B, The muscle is exposed with its fascia fully elevated.

Creation of the subpectoral pocket

After fascial elevation, dissection proceeds medially to identify the lateral border of pectoralis major. The inferior costal attachments are released to develop the subpectoral pocket and permit lower-pole expansion. The medial attachments along the sternum are preserved, with pectoralis minor and the ribs left intact beneath the pocket.

Combined muscle and fascial coverage

The completed pocket places pectoralis major over the upper inner implant and serratus anterior and/or external oblique fascia over the lower outer implant. This continuity of muscle and fascia is the defining feature of the modification. The authors report that fascial harvest added approximately 5–10 minutes to operating time.

Figure 4. After fascia elevation, lateral border of PM muscle and under-lying loose areolar tissue are encountered.

Closure and reported recovery

Following pocket preparation, the authors describe haemostasis, irrigation, implant placement and layered closure. No drains were used in this series. Patients reportedly returned to daily activities within one week, with exercise restricted for four weeks; these observations describe the study’s recovery experience rather than a universal postoperative timetable.

Figure 5. After creating a pocket, the elevated fascia (white arrow) is connected to the pectoralis major muscle (black arrow).

Complication Management

The main focus is preventing implant visibility and rippling through better coverage. During follow-up of 18–36 months, the authors reported no Haematoma, Seroma or implant displacement. They also reported maintained nipple–areola sensitivity and no visible or palpable implants. Mean follow-up was 25.6 months.

The proposed mechanism is straightforward: a continuous fascial layer adds coverage where the tissue envelope is thin. Preserving its integrity is therefore central to the technique. The study provides encouraging observations, but it does not set out a treatment pathway for complications that develop after surgery.

For inadequate coverage and rippling, the discussion considers acellular dermal matrix and autologous fat grafting as alternative approaches. The authors describe practical trade-offs, including matrix cost and complications, variable fat survival and limited donor tissue in thin patients. Their series did not directly compare these options with fascial coverage.

The findings come from a small series without a control group. They cannot establish superiority over conventional dual-plane augmentation or determine uncommon and longer-term risks. In particular, the study does not demonstrate a reduction in long-term capsular contracture or re-operation rates.

Figure 6. A and B, Preoperative view of a 24-year-old patient. C and D, Postoperative view approximately 4 months after breast augmentation using anatomical cohesive gel implants, 295 ml on the right side and 255 ml on the left side.

Figure 7. A and B, Preoperative view of a 27-year-old patient. C and D, Postoperative view approximately 8 months after breast augmentation using 255 ml anatomical cohesive gel implants.

Conclusion

The modified dual-plane approach described by Hwang and colleagues addresses the lower outer implant coverage that can be challenging in thin patients. By combining pectoralis major with serratus anterior and, where appropriate, external oblique fascia, the technique aims to improve concealment while allowing the lower breast to expand.

Its main educational value lies in connecting implant selection with tissue assessment and pocket design. The reported results support further consideration of fascial coverage in selected primary augmentation patients, while the small study size and absence of comparative data remain important limits. For breast lifting, separate evidence is required because Mastopexy was not evaluated.

Reference

Hwang DY, Park SH, Kim SW. A Modified Dual-plane Technique Using the Serratus Anterior Fascia in Primary Breast Augmentation. Plastic and Reconstructive Surgery – Global Open. 2017;5(2):e1213. DOI: 10.1097/GOX.0000000000001213.

---

Explore Korean advanced aesthetic breast augmentation and lifting techniques through live surgery observation, focusing on minimal scarring and complication management. IFAAS Mini Fellowship (In-OR Observation)​

Korean Advanced Aesthetic Breast Augmentation - Minimal Scarred Breast Augmentation & Breast Lifting 

18-19 March, 2027, Seoul, South Korea - [Register Now]