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.

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.

Hello Zsuzsika26,

Subfacial breast augmentation has not shown to be any different than subglandular breast augmentation in terms of risks, benefits, or appearance.  Some women could potentially be good candidates for subglandular breast augmentation and therefore also subfacial augmentation. However, subpectoral breast augmentation with properly sized implants will lead to the best aesthetic results for the majority of women.

Best of luck!

I do not perform subfascial breast augmentation. The fascia over the muscle is paper thin and does not afford any benefit in my opinion over a standard subglandular pocket dissection.

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.

I too don't believe that there is enough fascia over the pectoralis muscle to dissect under and to place an implant there. The implant either goes over the muscle or partially under. It is not a real operation just a con. I have been doing this surgery for over 30 years and teach residents and fellows and dont believe in this procedure.

I use the subfascial approach only in patients who fulfill the following criteria:  only in patients who want gel implants and have at least a pinch test of one inch in the upper aspect of the breast. There is a greater risk of developing rippling with saline implants or if there is not enough tissue to cover the implants. This approach allows the breasts to settle more quickly so that you will reach your final result faster.  There is much less pain postoperatively with the subfascial approach.  One is able to return to work sooner.  I have not found there to be any difficulties performing mammography.  In a patient requiring a lift a subfascial implant with fill out the skin envelope better providing a nicer result.

Many feel that subfacial breast implants, those placed under the thin filmy covering tissue on the chest muscle,  are an illusion, and the pocket is actually subglandular in structure and performance. We too feel that is true and subfacial is more of a marketing technique than a surgical one. Still, there is a time a place for a subglandular augmentation and it might be the right one for you.

Best of luck, peterejohnsonmd.com

The ideal breast augmentation is the creation of a larger, attractive breast. Since all breat implants ripple (saline worse than silicone filled implants)they have to be covered with as much soft tissue as possible. That is the reason why most saline implants are placed under BOTH the breast gland AND the underlying Pectoralis Major muscle. The less coverage over these rippling, creased implants, the more these folds and ripples will be seen and felt at the urface of the augmented breast. 

What is the fascia? It is simple a white connective tissue lining on the surface of every muscle in the body. While the thickness of the fascia varies from area to area , the fascia of the Pectoralis major muscle is extremely thin (thereby contributing NO thickness of coverage of ripples) and densely attached to the muscle making lifting it in one piece hard and a surgical exercise in uselessness.  Placing a rippled breast implant under a wet Kleenex like fascia provides ZERO coverage of the ripples and offers NO benefits. 

So WHY do some surgeons sell this procedure? It's a financially motivated not a scientifically based decision. 

Your skepticism was correct.