The case against medial pectoral releases: a retrospective review of 315 primary breast augmentation patients.

Although medial pectoral releases have been recommended as an important component of retropectoral breast augmentation surgery, there has been no study that documents the benefit or need for this potentially harmful surgical maneuver. In this study, 315 patients were retrospectively reviewed to determine the effect of medial pectoral muscle releases on breast implant position, visibility, and palpability. Five patients had incomplete data, leaving 310 patients available for photographic and clinical analysis at an average of 25.7 weeks postoperatively (range 5.61-91.6 weeks). All patients received textured, saline-filled, round, retropectoral implants. Group I (n = 163) had partial medial pectoral releases to the level of the superior aspect of the areola. Group II (n = 152) had no releases; however, retropectoral pocket dissection was extended medially to the arc of the median raphe, where the tendinous origins of the pectoralis major muscle are firmly anchored to the anterior aspect of the sternum. To assess implant position, the ratio of the intermammary space to the lateral breast protrusion (IMS/LBP) was compared for all patients. There was a greater decrease in the average IMS/LBP ratio in group II compared with group I, (P = 0.0315). This indicates that subpectoral mobilization to the arc of the median raphe afforded a proportionally decreased intermammary space, better medial envelope fill, and less lateral implant displacement when compared with medial pectoral releases. Five patients (3%, P = 0.014) developed breast implant visibility and palpability on the medial aspect of the breast mounds, and 2 patients (1.2%) developed hematomas in group I. One patient (0.6%) developed implant distortion with muscle flexion in group II. To explain these results, 6 pectoral muscles were dissected in 3 female cadavers. Above the fifth rib and below the clavicular head, the secure, tendinous origin of the pectoralis major muscle arises from the central anterior aspect of the sternum forming an "arc of the median raphe." This anatomic feature allows pectoral muscle mobilization medially, negating the need for division. Maintaining the integrity of the pectoral muscle affords decreased implant visibility and palpability medially and decreased patient morbidity while delivering possibly improved esthetic proportions by decreasing the intermammary space.