Breast Augmentation with Inferior Muscular Support: The Indication, Technique Evolution, and Outcomes

Smooth implants, favored for their lower risk of rupture and BIA-ALCL, encounter stability challenges in preventing implant displacement and bottoming out. Therefore, a stronger support of the lower pole is necessary to immobilize the implant. Various techniques, which involve manipulating the pectoralis major (PM) muscle, serratus anterior muscle (SAM), external abdominal oblique muscle (EOAM), and their fascia to create a muscle-fascia pocket, have emerged as strategies to ensure implant coverage and improve stability. In this review, we redefine and categorize these surgical approaches into two types: mono-muscular flap (MMF) and bi-muscular flap (BMF). These advancements reflect evolving trends and principles in breast augmentation, emphasizing the importance of both implant coverage and stability. Clinical evidence suggests that techniques with lower-pole support are particularly beneficial for patients at high risk of implant displacement or ptosis, as well as those undergoing revision surgeries. Further refinement of techniques that compromise the conflict between muscle support and release should be of greater concern.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .