Tissue Preservation in Primary Breast Augmentation: From Founding Concepts to Early Evidence

Abstract

Level of Evidence: 5 (Therapeutic)  

Between the 2 of us, we have more than 6 decades of breast surgery expertise. One of us championed implant placement above the muscle in the subfascial pocket and has spent a career refining that philosophy.^1,2 The other arrived at her preference for the prepectoral plane first through breast reconstruction, then aesthetic procedures, and has advocated for leaving the pectoralis undisturbed ever since. We come to this supplement from different directions, different countries, and different patient populations. We read these 4 papers and reached the same conclusion. They are united by a single idea that the breast performs better when surgery respects the anatomy. This supplement is where the founding concepts of tissue preservation meet early clinical evidence.

Rather than loosely related studies assembled around a product launch, the 4 papers provide an elegant architecture and move deliberately from molecular mechanism to cadaveric anatomical validation, to multicenter US early experience, to single-center outcome validation. Each paper builds on the last and provides the layered structure that our specialty should demand of any technique claiming to represent a genuine advance. It reflects what becomes possible when implant technology genuinely advances, anatomy is understood more deeply, and our community can follow the evidence toward something better for our patients.

THE FOUR PAPERS

Calobrace and colleagues open with a review of the biology.³ Anchored in the 2021 Doloff et al study in Nature Biomedical Engineering, the paper establishes that surface topography is an active immunologic variable that modulates the host response.⁴ The 4-micron SmoothSilk surface preferentially recruits regulatory T cells rather than proinflammatory macrophages, produces thinner and more compliant capsules across multiple animal models and human explant series, and carries no reported breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) cases in over 15 years of global postmarket surveillance.^5,6 Its effective surface area is comparable to conventional smooth devices, which distinguishes it from macrotextured designs with significantly higher bacterial adhesion potential. This is not a marketing claim, but a mechanistic description with published evidence behind it. This narrative review paper synthesizes the cellular and clinical evidence to show that the 4-micron surface actively modulates the foreign body response toward immunomodulation and controlled healing. When this is combined with a surgical technique that causes minimal disruption to the tissue, this modulation can operate without the inflammatory interference that would otherwise overwhelm it.

Lhuaire, Chacón-Quirós, Rehnke, Graf, and colleagues then establish the anatomical foundation on which the technique rests.⁷ Across 16 cadaveric dissections at 2 academic anatomy centers, they confirm that the posterior intralamellar plane is a consistent, histologically verified compartment between the corpus mammae and the pectoralis major fascia, present in all specimens and devoid of glandular tissue. Further anatomic refinement exists within this preexisting plane because it contains no significant vascular structures and its laminated architecture can be accessed atraumatically with balloon-assisted expansion rather than forcing a new plane with cautery. The technique operates entirely within the natural boundaries of the circummammary ligament, and Cooper's ligaments are displaced, not divided, during balloon-assisted expansion of the intralamellar plane.⁸ Histologic staining demonstrates that correctly executed intralamellar dissection places the implant in a parenchyma-free plane, with no glandular tissue deep to the device. The cadaveric evidence of that anatomic distinction underpins the long-term stability and imaging arguments made throughout this supplement.

Pittman and colleagues⁹ provide the early US experience with the balloon-assisted dissection technique: 161 patients across 5 centers and 6 months, with a surgeon roundtable that gives the paper practical value beyond its outcome data. The safety profile is reassuring for a learning-curve cohort: 0 hematomas, 0 sensory disturbances, 0 abnormal pain, and a combined early complication rate of 1.86%. That 64% of procedures were performed under local anesthesia with sedation reflects both the reduced tissue trauma and a meaningful expansion of access for patients who would otherwise decline surgery.

Chacón-Quirós and colleagues¹⁰ close the supplement by validating outcomes in 111 consecutive patients across 2 cohorts, with 12 months of follow-up, 3-dimensional imaging, and high-resolution ultrasound. Employing a geometric morphologic analysis framework (GMA-BA), the paper evaluates the breast as a system of regional deficits rather than a uniform volume, a more precise lens than conventional volumetric assessment. It shows that selective implant positioning within a preserved tissue envelope produces consistent aesthetic results with smaller implants than standard approaches require. Upper pole fullness improved in over 97% of patients, nipple projection alignment held in more than 95%, and lateral displacement did not increase at 12 months despite added implant weight. These findings reflect a tissue environment that has not been destabilized by surgical intervention.

THE CHAIN OF REASONING

The chain of reasoning that connects these 4 papers is respect of the anatomy. Balloon-assisted pocket creation does not divide vessels. It stretches them. Progressive elongation closes vessels mechanically without the open bleeding lumen that dissection produces. No intraoperative bleeding was reported across hundreds of procedures in these series. That is not a coincidence. The procedure follows a logical sequence. Avoiding vessel division limits bleeding. Limiting bleeding reduces blood-driven inflammation in the periprosthetic space. Less inflammation, combined with a surface that promotes regulatory immune activity rather than sustained macrophage activation, means less fibrotic capsule formation. Each step in that chain is supported by a distinct paper in this supplement.

TWO PERSPECTIVES, ONE CONCLUSION

We come to this supplement from different surgical traditions and different patient populations. The science and the anatomy have brought us to the same place. Balloon-assisted tissue dissection is not the only technique in the prepectoral space, and it will not suit every patient. But it is a valid option for carefully selected patients, built on a genuine scientific foundation. The biology is credible, the anatomy is confirmed, and the early outcomes are consistent. That is enough to support it with appropriate training, honest patient selection, and a commitment to reporting long-term outcomes.

Both of us carry appropriate caution. Follow-up is short in 2 of the clinical papers at 6 months and 12 months respectively, and capsular contracture, implant malposition, and size changes do not fully declare on that timeline. Previously published series from Randquist and the 3-year Chacón-Quirós prospective study both report 0 grade III or IV contracture, 0 malposition, and 0 BIA-ALCL at 3 years, which is encouraging.^11,12 That said, all 4 papers in this supplement originate from within the technique's own development ecosystem, and independent, randomized replication from unaffiliated centers remains the next necessary step. It is worth noting that Motiva requires formal certification before surgeons can access balloon-assisted dissection materials, which means the outcomes reported here reflect a consistently trained population, and future independent data will by definition come from surgeons held to the same standard. The longer-term answers will come from the surgeons who adopt carefully and report honestly.

This technique is not a refinement that experienced surgeons can absorb from a paper and a single case. For surgeons trained in anatomically observed, electrocautery-guided dissection, this technique represents a genuine cognitive and tactile shift with a learning curve. Ultrasound-guided infiltration, balloon-assisted expansion, and no-touch insertion through a 3-cm incision are not skills absorbed from reading. The surgeon roundtable in the Pittman paper is direct about this. Incorrect plane infiltration risks glandular injury, pocket contamination, bleeding, and malposition, because the channel separator and balloon follow the path of least resistance. This is precisely why the certification pathway for this technique should be treated as a patient safety standard, not an optional credential.

These papers carry no criticism of surgeons who have placed implants beneath the pectoralis major for the past 50 years. Subpectoral augmentation was the right technique for its era. The posterior intralamellar plane had not been histologically characterized. The 4-micron immunologic data did not exist. Sixth-generation gel properties had not been developed. The surgeons who built the field made sound decisions with the science available to them, and their patients benefited from those decisions. What these 4 papers offer is not a repudiation of the past. They offer a path forward built on anatomy understood more precisely, implant biology understood more deeply, and early clinical experience with a technique designed to work with the breast rather than against it.

Tissue preservation surgery is not a refinement at the margins of surgical technique. This supplement compels a fundamental reconsideration of what breast augmentation can and should be, and provides the early scientific foundation on which that reconsideration can be built. The obligation now is rigorous evaluation, proper adoption, and honest contribution to the longer-term data.

Disclosures

Dr Graf has received research support and serves as a consultant and medical educator for Establishment Labs (Motiva, Alajuela, Costa Rica). No compensation was provided for the writing of this editorial. Dr LeBlanc received reimbursement for travel expenses from Establishment Labs (Motiva) for education on the Preservé technique and has served as a remunerated advisory board consultant for Establishment Labs (Motiva, Alajuela, Costa Rica), BD (Becton Dickinson, Franklin Lakes, NJ), Allergan/AbbVie (Irvine, CA), Bimini Health Tech (Plano, TX), Evergen (Alachua, FL), and related entities. No compensation was received for the writing of this editorial.

Funding

The authors received no financial support for the research, authorship, or publication of this article.

Supplement Sponsorship

This article appears as part of the supplement “The Building Blocks of Breast Tissue Preservation,” sponsored by Establishment Labs Holdings Inc. (Coyol, Alajuela, Costa Rica) which provided funding for publication.