Subfascial vs submuscular for me? (Photo)

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.
 Subglandular Augmentation (“overs”): 
Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also fasterSubglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling when compared to subpectoral augmentation.Subglandular implants can also create the illusion of improved cleavage by preferential over-dissection of the central/medial pocket allowing the implants to be forced more to the midline. There is no limiting muscle as there is in a submuscular augmentation. 
Subpectoral Augmentation/Sub-muscular (“unders”): 
Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.Subpectoral implants have a lower rate of capsular contracture.Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.In my practice, the vast majority of augmentations are submuscular (technically these are all dual plane once the muscle is released). In your case specifically, with a concern for tissue coverage,  I would recommend submuscular placement.
As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Hello and thank you for your question. There are several advantages
and disadvantages to over vs under the muscle.  Under the muscle has the
advantage of lower capsular contracture rates, less risk of rippling, and
better visualization with future mammograms.  Most patients say that under
the muscle also has a more natural look and feel.  The size, shape,
and profile of the implant is based on your desired breast
size/shape, your chest wall measurements, and soft tissue quality. 
This decision should be based on a detailed discussion with
equal input from both you and your surgeon.  This entire surgery can be performed with a
small incision technique.  Make sure you specifically look at before
and after pictures of real patients who have had this surgery performed by your
surgeon and evaluate their results.   The
most important aspect is to find a surgeon you are comfortable with. I
recommend that you seek consultation with a qualified board-certified plastic
surgeon who can evaluate you in person.
Best wishes and good luck.
Richard G. Reish, M.D.  FACS
Harvard-trained plastic surgeon

Hello and thank you  for  your question  and photograph.
 205 c.c is optimal size for your width.. .. smaller implant will be  properly covered with breast tissue so  chance of rippeling or narrowing off pocket are less. You will have natural look. Recovery will be faster.
Best of luck. 
Dr Milan Doshi. Mumbai

Thank you for your answer. There is ample evidence nowadays that the best outcome after Breast Augmentation is achieved by three steps: 1- tissue based planning which means that the size of your implant is determined by measurements taken based on your anatomy and skin quality 2- dual plain pocket insertion (not subfacial nor subglandular) 3- no touch technique by using a special funnel to insert the implant. If those three steps are not being followed in your surgery I advise you to take a step back and do your homework again in more depth before it is too late. Best of luck,Shady Hayek

In my  opinion subfascial do not really offer any more benefit than a subglandular implant.  I prefer in most cases to place them in a submuscular pocket.

Hi,
Thanks for the question
I will tend to agree with the  logic of your Plastic surgeon to be superficial placement of implant for you.
Under the muscle implants can not be placed too close together since the muscle attachment to the medial parts of ribs in the upper 3 to 4 ribs have to  be left intact that does not allow implant to be together to have any kind of cleavage and therefore its not a good idea with those like you who have broad shoulders .
For a 205 cc implant you do have enough skin..In fact,if you like to go larger you may use up to 275 cc implants  provided you do like a full B cup or a small C cup breasts.
I wish you all the  best