What's Your Opinion on the Sub-fascial Breast Implant Compared to Subpectoral?

Hi there-

The idea with sub-fascial breast augmentation is to combine some of the best aspects of sub-glandular (above the muscle) placement- namely less pain in the postoperative period without the risk of muscular distortion during exercise- and subpectoral (under the muscle placement (lower rate of capsular contracture and visible rippling.

Just like so many other ideas in the history of plastic surgery (the thread facelift, teardrop shaped implants...), the logic and reasoning behind the concept sound compelling, but most experienced breast surgeons at this point agree that in practice the technique is no different (in terms of the patient outcome and experience) than just placing the implants on top of the muscle.

The reason is that the fascia the implants are being placed under (the superficial pectoral fascia) is a very thin layer of tissue that thins even more after an implant is placed under it- so that after a few months, there is really no difference in the incidence of rippling and the ability to feel the implant through the skin, and the fascia does not provide as much support for the implant as the muscle would.

For all of these reasons, this technique has fallen out of favor and many responsible and ethically minded surgeons consider it no more than a gimmick designed to attract patients at this point.

Thank you for the question.

At this point in time, I do not use the “sub–fascial” space for  breast augmentation surgery;  I believe that it is essentially equivalent to using the sub glandular space.  Placing breast implants  superficial to the pectoralis muscle layer does have significant disadvantages.

The sub muscular posiutioning of breast implant allow for more complete coverage of the breast implants leading to generally more natural feel/look  of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability  of the implants (which may increase with time, weight loss, and/or post-pregnancy changes).

The submuscular positioning  also tends to interfere with mammography less so than in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position.

I hope this helps.

Most people think of implants as either over or under the muscle, but in reality it is a bit more complicated. Under the muscle involves cutting the muscle attachment to the rib cage and can lead to what are called animation deformities. One way to prevent that while still having some muscle coverage over the upper breast (where it is most needed) is a split muscle technique, which avoids cutting the muscle. The fascia is a thin layer on the surface of the muscle so it can add some support to the implant but not much more coverage than the usual way of placing implants on top of the muscle. So you have subglandular, subfascial, split subpectoral, and submuscular (also called subpectoral and dual plane.) I have 2 articles on the subject which I would be happy to send.