Breast and chest wall layers

The breast sits on the chest wall inside a pocket of superficial fascia, in front of the pectoralis major muscle. An implant goes behind the gland, behind the pectoral fascia, behind the muscle, or in a dual plane that mixes the two.

Techniques

Outside to inside

The layers of the breast and chest wall

1. Skin and nipple-areola

The nipple and areola are supplied by branches of the 3rd, 4th and 5th intercostal nerves; the 4th lateral branch was the most constant, in 79% of 28 cadavers. Regnault graded sagging by where the nipple sits relative to the fold under the breast.[1][2]

2. Superficial fascia and Cooper ligaments

A superficial and a deep layer of superficial fascia encase the breast in a pocket and condense into one layer around its edge. Cooper ligaments divide the breast tissue.[1]

3. Breast gland

The gland holds fat as well as glandular tissue: Lejour suctioned 100 to 1,000 cc of fat from 86 breasts before reduction, and removed 120 to 1,600 g per breast. A subglandular implant sits directly behind the gland, over the muscle.[1][2]

4. Inframammary fold

The fold under the breast supports and defines the lower pole. The inframammary incision is placed in it. In a meta-analysis, periareolar incisions had more capsular contracture than inframammary incisions (odds ratio 1.91).[1][2][3]

5. Pectoral fascia

The lateral nerve branches to the nipple run deep within the pectoral fascia in 93% of breasts. Graf placed implants in 263 patients between this fascia and the muscle, the subfascial plane.[1][2]

6. Pectoralis major and chest wall

A partial retropectoral pocket sits behind the pectoralis major; a total submuscular pocket sits behind the pectoralis major and serratus. Across 51,524 patients, capsular contracture was 1.83% submuscular and 6.85% subglandular.[1][2]