A Modified Bimuscular Flap Technique for Breast Augmentation: Does Extra Muscle Support Enhance the Stability of Smooth Implants?

Background: Because of concerns related to breast implant–associated anaplastic large-cell lymphoma, smooth implants are being increasingly used instead of textured breast implants. However, lack of sufficient lower-pole support for smooth implants using the dual-plane method may give rise to complications, including rippling, implant malposition, and bottoming out. Therefore, the authors developed a modified bimuscular flap technique. Methods: In the presented technique, the pectoralis major muscle is split through the intramuscular space to dissect the lateral and medial muscular flap, the inferomedial costal origins are released, and the pectoralis major is released through a T-shaped incision and adjusted to accommodate the required pocket volume. Long-term complications were compared between the modified and dual-plane techniques in patients who were followed up for at least 6 months. Results: A total of 275 patients undergoing bilateral breast augmentation with the modified technique using smooth implants were included. Their average body mass index was 18.50 kg/m 2 . Among the 253 patients followed up, the following postoperative complications were recorded: grade 3 capsular contracture (0.6%), mild muscle contraction–associated deformity (7.1%), lateral rippling (3.2%), implant malposition (1%), and bottoming out (0.2%). The rates of lateral rippling, implant malposition, bottoming out, and revision surgery were significantly reduced compared with the dual-plane technique. Conclusions: This modified bimuscular flap technique incorporates implant coverage and appearance control while balancing muscle release and support, achieving satisfactory long-term outcomes. The lower rates of rippling, implant malposition, and bottoming out make it preferable for very thin patients or those using large implants. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.