Subfascial placement without internal bra? (photo)

Question

I am planning to get my breast done soon. I want quite a drastic change. The doctors I have had consultation with have said if I go under the muscle the limit will be 300-400cc Another doctor said for 500-600cc we can opt for subfascial placement. I am doing research as she lots of people with subfascial placement get internal bra (gala). The doctor said he doesn’t recommend it due to risk of infection. I am wary now

Gary M. Horndeski, MD · Answer

Unfortunately, you have not told us your bra size. If you are size 32 or 34, each 100 cc of implant corresponds to 1 cup size change. If you are size 36 or 38, each 200 cc of implant corresponds to 1 cup size change. From this, you can compute the volume required to achieve your desired goal.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

John L. Burns Jr., MD · Answer

The risk of larger implants is inferior and lateral displacement over time.  The internal bra does help maintain the shape and implant position over time.  I don't agree with the risk of infection being any higher with an internal bra.

Ted Eisenberg, DO, FACOS, FAACS · Answer

After I measure and discuss goals with my patients, we then look at pictures of women (my patients) with similar measurements with different size and style breast implants. They also get to see what they would look like when the breasts have fully dropped and fluffed and in clothes. You get to see actual results and the surgeon's experience and not a virtual idea of what can be achieved. Women tell me that this process is very helpful in determining what size and style breast implant is right for them. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Alireza Tehrani, DO · Answer

Hi there- There has been a shift away from placing implants under the muscle over the last few years. Myth! Mesh does NOT increase chance of infection and anyone who uses that excuse to not place mesh does not know how do it correctly or does not understand the procedure. I agree larger implants in the subfascial plane can be tricky based on your starting point but using galaflex or an equivalent mesh is paramount! Hope that helps.

Daniel Barrett, MD · Answer

Dear Versatile632284,

I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Gerald Minniti, MD, FACS · Answer

Mesh does not increase the risk of infection. Implant selection is not limited per se by implant position, i.e. under muscle restricts size selection, but the risk of animation deformity is higher when implants are 'too big' for the subpectoral pocket. The craze of subfascial implant position is being propagated mostly by young surgeons who haven't had the opportunity to see the long term changes that occur in the soft tissues of the breast after 10 or 20 years of implants over the  muscle. Regardless of which implant position you choose, there are still limitations to size. The woman in your goal photo had more skin in the lower pole of her breasts, allow for more capacity for a larger implant; you would not look like this with that size implant. You need to start thinking in a more long term way about breast augmentation and the choices you make now may create problems that are difficult or impossible to fix, with every revision surgery opening the door to new complications.

Paul E. Chasan, MD, FACS · Answer

Thank you for your question.  I have been in practice over 30 years, and a large portion of my practice is dedicated to revision breast surgery.  I have a whole gallery on my website "chronic changes associated with implants on top of the muscle". If you have ever seen the fascia of the pectoralis major muscle, it is no thicker than tissue paper.  It is one of the most deceiving comments in plastic surgery.  Essentially, a subfascial breast augmentation IS a subglandular breast augmentation. Once you disconnected the breast tissue envelope from the muscle and add the weight of an implant, the only force that is working is gravity.  Over the years, I have seen this scenario so many times in which the patient got a subglandular breast augmentation only to be totally disappointed 6 months later that the implants have now dropped significantly. There should be no difference in the amount of implant volume that you can place either under the muscle or over the muscle.  You should be able to have an excellent result.  Best wishes to you.

Connie Hiers, MD, FACS · Answer

Stay with the 400 cc size, for the 500-600 size will be too large and heavy for your frame and tissue, and you may bottom out later. Plus, the large implants stretch and thin your own tissue a lot. When you are older, you will want to downsize and may be more limited because of thin tissue in what can be done. The 300-400 cc size will be good for life.  The lady in your wish photos will be sagging soon.  Implants that are too large for your frame will also make you look fat.

Camille Cash, MD · Answer

Bioabsorbable mesh is helpful for those needing extra support for the tissue.  You can definitely have the mesh at the same time as augmentation.  Be sure when you are selecting your implant that you are considering which will look best on you, not just what the largest size is that you can get.  Many surgeons have sample implants that you can "try on" to give you an idea of how you may look after surgery.