This post begins a new series: Aesthetic Plastic Surgery.
The Foundations posts asked what a plastic surgeon is by looking at papers that still train us — skin grafts, Z-plasty, autologous breast reconstruction. This series turns to the aesthetic literature with the same educational aim: read a flagship article carefully, place it in its lineage, and say what it still teaches in practice.
We start with breast augmentation — specifically with a 2000 paper from Curitiba that helped put the subfascial plane on the map, and with the related studies that followed it into wider use.
The paper
Graf RM, Bernardes A, Auersvald A, Damasio RCC. Subfascial Endoscopic Transaxillary Augmentation Mammaplasty. Aesthetic Plastic Surgery. 2000;24(3):216–220. doi:10.1007/s002660010036
In 2000, Ruth Maria Graf and colleagues published this retrospective series in Aesthetic Plastic Surgery. The work came from their private clinic in Curitiba, Brazil. They described videoendoscopic breast augmentation through an axillary “S”-shaped incision, with implants placed in the submuscular, subglandular, or — more recently in their practice — subfascial plane.
The series included 62 patients, ages 15 to 48, followed over a three-year window. Plane distribution was 49 submuscular, 5 subglandular, and 8 subfascial. They used textured anatomic cohesive-gel implants (McGhan 410; 155–235 g).
Reported outcomes were favorable for what the paper set out to show. Patient satisfaction was high, especially with the axillary scar kept off the breast. No capsular contracture was observed in the series as reported. Complications were few: one hematoma treated with ultrasound-guided drainage, and two implant malpositions (rotations) managed with endoscopic repositioning through the same axillary access.
That is why this paper earns flagship treatment here. It supports endoscopic transaxillary augmentation as a safe option, and it shows that the same approach can be used across prefascial/subfascial and submuscular planes — with the authors already favoring subfascial placement for a more natural upper-pole transition without the lower-pole flattening they associated with fully submuscular implants.
A fair criticism, and one worth stating plainly: this was a retrospective review without a control group. It describes experience and early preference. It does not compare planes head-to-head under controlled conditions.
Lineage: endoscopic transaxillary first
Graf’s 2000 paper did not invent endoscopic transaxillary augmentation. It built on it.
In 1993, Lawrence C. Y. Ho published Endoscopic assisted transaxillary augmentation mammaplasty in the British Journal of Plastic Surgery. That paper is widely recognized as an early — and, in this lineage, the first clear — description of endoscopic assistance for the transaxillary approach: direct visualization of the pocket through a hidden axillary incision, with precision that blind dissection could not match.
Graf and colleagues themselves place Ho in that sequence. The 2000 paper sits downstream of that endoscopic idea, then adds the plane question that became their lasting contribution: not only how to see the pocket from the axilla, but where to place the implant relative to the pectoralis fascia.
Benito-Ruiz, 2003: cadaver and clinic
Benito-Ruiz J. Transaxillary Subfascial Breast Augmentation. Aesthetic Surgery Journal. 2003;23(6):480–483. doi:10.1016/j.asj.2003.08.006
Jesús Benito-Ruiz followed with a focused clinical note that combined cadaveric observation of the subfascial plane with a small clinical series. Between January 2001 and June 2002, he performed the technique in 16 patients using round textured silicone gel implants (220–350 cc).
He reported no postoperative complications in that series, no long-term sensory disturbance of the nipple-areolar complex or the medial arm, and no capsular contracture. Transient axillary subcutaneous banding occurred in six patients and resolved within three months.
His framing versus submuscular placement is practical and still familiar: less risk of hematoma, less pain, faster recovery, less likelihood of injury to the intercostobrachial nerve, no loss of aesthetic outcome relative to what he expected from a subglandular result, and avoidance of animation deformity from muscle contraction. He also noted, from dissection and surgery, that coverage is not purely subfascial throughout — the lower pole sits under gland — while the fascia helps conceal the upper implant edge that can show in a pure subglandular pocket.
Graf, 2003: the larger subfascial series
Graf RM, Bernardes A, Rippel R, Araujo LRR, Damasio RCC, Auersvald A. Subfascial Breast Implant: A New Procedure. Plastic and Reconstructive Surgery. 2003;111(2):904–908. doi:10.1097/01.PRS.0000041601.59651.15
Three years after the endoscopic transaxillary paper, Graf and colleagues published a fuller description of the subfascial procedure in Plastic and Reconstructive Surgery. From October 1998 through September 2001, 263 patients underwent breast augmentation with implants placed in the subfascial plane (McGhan 410; 155–310 g).
They argued for a middle path: avoid the implant deformation and distortion associated with retromuscular placement, keep additional soft tissue between implant and skin, and reduce edge prominence that can accompany retroglandular placement. In that series, none of the patients were reported to have implant distortion or palpable edges. Capsular contracture occurred in 6 patients (about 2.3%; Baker grade II in the reported accounting). Three patients had unilateral hematoma requiring reoperation; eight had unilateral implant malposition requiring reoperation. There were no infections.
Those numbers matter for how we talk about technique. Complication rates that look “good” are never zero. A useful method is one that keeps them low and manageable — not one that pretends they disappear.
Hunstad, 2010: a U.S. comprehensive experience
Hunstad JP, Webb LS. Subfascial Breast Augmentation: A Comprehensive Experience. Aesthetic Plastic Surgery. 2010;34(3):365–373. doi:10.1007/s00266-009-9466-1
Joseph P. Hunstad and L. Shayne Webb later reported a comprehensive North American experience with the subfascial plane. Between July 2007 and April 2009, 61 patients underwent subfascial augmentation — primary cases, secondary conversions, concurrent mastopexy — through inframammary, periareolar, and endoscopic transaxillary approaches. Follow-up among returning patients ranged from 2 to 24 months.
They reported high patient and surgeon satisfaction, few complications, a low capsular contracture rate (none in their series as reported), no animation deformity with arm movement, and no compromise of aesthetic results of the kind that would argue against the plane. Their conclusion matches the idea Graf had been developing for a decade: for the properly selected patient, subfascial placement can combine advantages associated with both subglandular and submuscular pockets while avoiding some of the disadvantages of each.
Hunstad and Webb also credit Graf with first performing subfascial breast augmentation in 1998 and with documenting the rationale that brought the technique into wider awareness — including into U.S. practices that adopted it after her presentations and publications. Graf’s own work was based in Brazil. What traveled was the technique and the literature, not a simple claim that she “moved” the operation to the United States as a single historical event. That distinction is worth keeping clean.
Optimization, longevity, and practice
What impresses me most in Graf’s later reflection on this work is not only the plane itself, but the posture behind it.
She writes as someone who is always looking to optimize a procedure — the same orientation I try to keep for operations learned in training and refined in practice. The themes are familiar because they are keystones of plastic surgery: less surgical trauma when possible, less scarring when possible, and better results when the anatomy allows it, without trading those gains for a higher complication burden. Subfascial placement through an endoscopic approach is one place those goals show up together. Optimal results with minimal invasion, minimal scarring, and minimized complication risk remain continual advancing aims in our literature and in the operating room. The subfascial pocket, as developed in this lineage, offers a natural-looking result that has been shown safe and effective without an increase in complications relative to that purpose.
Graf also thinks past the immediate photograph. In her reflection she notes how surprisingly little attention is paid to how future implants will be accommodated or handled — longevity and the patient’s overall course, not only day-one contour. That point lands close to home. It has been one of my larger personal criticisms of submuscular placement: the pocket that looks tidy at first may not be the pocket that serves the patient best when revision becomes necessary years later.
In my own revision practice, I more commonly transition from a submuscular pocket to a subfascial pocket than the reverse. I agree with Graf that subfascial placement is typically ideal for both immediate and long-term results when the patient and the tissues are appropriate for it. Both the inframammary fold and the transaxillary approaches are safe and effective routes to that plane; the choice is about access, scarring preference, and anatomy, not about inventing a different standard of safety.
What this flagship still teaches
Read together, these papers tell a coherent story.
Ho made endoscopic transaxillary augmentation visible and controllable. Graf used that access — and then the subfascial plane itself — to argue for a natural upper pole without submuscular animation and without the soft-tissue thinness of a pure subglandular pocket. Benito-Ruiz added anatomic and early clinical support for the transaxillary subfascial route. Graf’s 2003 series enlarged the outcomes picture. Hunstad’s 2010 experience showed the method traveling into broader aesthetic practice with high satisfaction and few complications.
The lasting clinical claim is not that subfascial is the only correct plane. It is that subfascial can combine advantages of both submuscular and subglandular placement, and that Graf’s work also added another dimension to breast augmentation through the transaxillary endoscopic approach — scar off the breast, plane under the fascia, visualization when the pocket demands it. Her optimization ethos and attention to longevity make that claim durable: a plane chosen not only for today’s shape, but for the patient’s next decade of care.
That is a fair flagship for the first post in an Aesthetic Plastic Surgery series: a paper that changed how many of us think about implant coverage, without asking us to forget the limits of retrospective series or the need to match plane to patient.
This post is educational journal discussion. It is not a substitute for peer-reviewed literature, individual clinical judgment, or patient-specific consultation.
Tobias C. Long, MD
Founding Member
References
- Graf RM, Bernardes A, Auersvald A, Damasio RCC. Subfascial endoscopic transaxillary augmentation mammaplasty. Aesthetic Plast Surg. 2000;24(3):216–220. doi:10.1007/s002660010036
- Ho LCY. Endoscopic assisted transaxillary augmentation mammaplasty. Br J Plast Surg. 1993;46(4):332–336. doi:10.1016/0007-1226(93)90015-4
- Benito-Ruiz J. Transaxillary subfascial breast augmentation. Aesthet Surg J. 2003;23(6):480–483. doi:10.1016/j.asj.2003.08.006
- Graf RM, Bernardes A, Rippel R, Araujo LRR, Damasio RCC, Auersvald A. Subfascial breast implant: a new procedure. Plast Reconstr Surg. 2003;111(2):904–908. doi:10.1097/01.PRS.0000041601.59651.15
- Hunstad JP, Webb LS. Subfascial breast augmentation: a comprehensive experience. Aesthetic Plast Surg. 2010;34(3):365–373. doi:10.1007/s00266-009-9466-1