Subglandular, subfascial or submuscular is better for me? (Photo)

Question

My concern is 1. my breast looks tubular (like horns) and 2. I want a little more volume to fill my upper pole but I don't want to look too fake (in other words I don't want my upper pole to have unnatural volume). I went for 2 consultations. First doctor recommended subfascial and second doctor recommended subglandular because I have enough breast tissue. I'm worried I might look like Victoria Beckham after breast feeding or if I lose weight. Should I be concerned about rippling or not?

Urmen Desai, MD, MPH, FACS · Answer

I recommend submuscular placement of the implants.  The implant selection should be based on a combination of your desired size, soft tissue dynamics, breast base diameter and skin elasticity.  I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with.   Finally, make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery (ABPS), a member of the American Society of Plastic Surgery (ASPS), a member of the American Society of Aesthetic Plastic Surgery (ASAPS), and a fellow of the American College of Surgeons (FACS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach TrainedDouble Board-Certified, Double Fellowship-Trained Beverly Hills Plastic Surgeon

William Bruno, MD · Answer

The submuscular (subpectoral) approach generally gives the most natural result; especially with regard to the upper pole volume. Your breasts are not very tubular or tuberous so I would not be too concerned about having an unnatural look. Rippling occurs more commonly with saline implants compared to silicone. Subglandular is associated with a higher capsular contracture (scar tissue) rate and is therefore not the ideal choice. You may need to consult with a few more plastic surgeons to gather more information before making your decision.Best wishes,Dr.Bruno

Robert Kearney, MD, FACS · Answer

Subfascial and sub-glandular are almost the same.  Sub-muscular gives you better coverage in the upper pole, maybe more important as you get older. There is a quicker recovery when you go over v under the muscle.  Implants over the muscle are more likely to ripple if you don't have enough coverage.  I think you need to trust your PS. It is a balance between the size the implant and the amount of breast tissue.  Looks like you would do fine either way with a small implant.

Tom S. Liu, MD, MBA · Answer

Thank you for your question! Implant placement is most often recommended to be submuscular for several reasons. When implants are placed below the muscle, there is a decreased risk for the development of capsular contracture (hardening) and less chance for rippling, which can be a concern for patients who are thin and have little breast tissue. Also, there is better mammography detection. Because you were given conflicting recommendations at your recent consultations, it is understandable to be worried! It may be helpful to inquire for the reasoning of the one surgeon who prefers subglandular. It may also be helpful to have an additional consultation appointment. Photos are unfortunately not a substitute for an examination by a board-certified plastic surgeon. Good luck in your research!

Gerald Minniti, MD, FACS · Answer

Hello,The small group of surgeons around the world who promote the concept of subfascial augmentation have failed to truly demonstrate that they are actually keeping the fascia in tact during the dissection or implant delivery phases of the surgery. Further, the fascia is anatomically thin (less than a mm), and offers no tissue buffer, leaving the implant exposed and prone to visible rippling.  Subpectoral surgery, along with inframammary incisions, are the part of a newly established 14 step plan to reduce complications as common as capsular contracture and as rare as breast implant associated anaplastic large cell lymphoma. Subpectoral placement will give you the most natural upper pole, avoiding the Victoria Beckham look. Go visit a few ABPS certified/ASAPS member surgeons.  Best of luck!

Daniel Barrett, MD · Answer

Dear friedrichickenislove,Determining the ideal breast size and matching that goal for the patient is the most difficult part of breast augmentation. It starts and ends with the patient. We have all of our patients find 3 photos of their desired breast size. We ask for naked breast photos because clothing can obscure the true size (push up bras). Next, we consult with patients and go over the photos and take detailed breast measurements during a physical exam. Next, we using a sizing algorithm to determine a range of implants that will work based on the exam and the measurements. Lastly, during the operation, we use silicone sizers in the operating room to see how the size actually looks in the breast. We sit the patient up in the operating room, while asleep of course, and compare the sizer result with their desired look photos. If its too small, we start the process over with a slightly larger implant. We don't stop until we get the perfect match. Of all of my breast augmentation patients, everyone of them have been happy with their size due to this detailed and meticulous process. You don't want to invest time and money into a result that is either too big or too small.Daniel Barrett, MD, MHA, MS 
Certified, American Board of Plastic Surgery  
Member, Am. Society of Plastic Surgery

Donovan Rosas, MD · Answer

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.
As always, discuss your concerns with your board certified plastic surgeon (ABPS).

Luis E. Redondo, MD · Answer

Choose the doctor not the technique. Every surgeon have a technique that on his hands works better and can deliver the result you want. In my hands I would choose a dual plane placement but that doenst make it the only viable option. Best of luck,

Johnson C. Lee, MD · Answer

Thank you for your photo. It is important to have an in-office evaluation to evaluate your breast tissue. There are pros and cons to each type of pocket for your implant. A subglandular will have the most power to change the shape of a breast from a tube to a round look, however there is a higher risk of rippling, especially if your breast tissue is thinner. A subfascial is very similar to a subglandular. A submuscular will give you more tissue coverage over the implant and reduce your risk of rippling. Both can be performed with a natural appearing result if the correct style and size of implants are correct. These fine details can be determined after your physical examination so all the information can be put together to get you closest to your goals and minimize your risks. Hope this helps!Johnson C. Lee, MD Plastic Surgery@drjohnsonlee

Robert Singer, MD · Answer

There are two choices for breast implant placement: sub-glandular (under the breast tissue and in front of the chest muscle – the pectoralis muscle) or sub-muscular (under or partially under the chest muscle). The best location depends on many factors including: tissue thickness, weight, desired outcome, and individual anatomy. Each position has advantages and disadvantages:
  
Subglandular implant benefits: (Similar for Subfascial)
A shorter      recovery time.
  Less      discomfort initially. 
  No distortion      of the breast when the pectoralis muscle flexes. 
  Mild      preoperative sagging can be improved, especially if no breast lifting      procedure is performed. 
  Easier      surgical procedure. 
  Larger      implants can be placed. 
  Subglandular implant disadvantages:  (Similar for Subfascial)
The implant      may be more visible. 
  More visible      rippling, especially in patients with a small amount of natural breast      tissue. 
  Generally,      saline implants do not produce a good result in front of the muscle. 
  Higher      incidence of capsular contraction. 
  “Bottoming      out” in some patients. 
  Some      radiologists have more problems reading a mammogram with an implant in      front of the muscle. 
  Submuscular implant benefits:
  
Usually      results in a better appearance for naturally small breasted women 
  Less tendency      for seeing ripples of the implant. 
  A more      natural feel to the breast especially in slender women who don’t have much      of their own breast tissue. 
  Less      interference with mammograms, although most radiologists take additional      views no matter where the implants are placed. 
  Lower rate of      capsular contraction. 
  Less of a      chance of “bottoming out” where the implant bulges at the lower aspect of      the breast and the nipple and areolas tend to appear excessively elevated.      
 Submuscular implant disadvantages:
  
Recovery      usually takes a little longer and is more uncomfortable initially. 
  There may be      an “animation deformity”, which is a temporary distortion of the breasts      when the pectoralis muscle is flexed. Body builders and weight lifters      generally prefer implants in front of the muscle. 
  It is harder      to achieve cleavage in women who have widely spaced breasts. 
  The implants      often ride higher on the chest.
 Actually, most patients who have breast augmentations today have breast implants placed in a combination or “dual plane” position. This approach has the same benefits and disadvantages of a total “submuscular implant”, but with a lesser tendency to ride high on the chest wall. The disadvantage as compared to a total “submuscular implant” is a higher tendency for bottoming out.
  
The ideal placement in any particular patient depends on their particular anatomy and understanding of the pros and cons of each approach and desired outcome.. 
  
Keep in mind, that following the advice from a surgeon on this or any other website who proposes to tell you what to do based on two dimensional photos without examining you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of each operative procedure may not be in your best interest. I would suggest you find a plastic surgeon certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person.   
  
Robert Singer, MD  FACS 
  
La Jolla, California

Subglandular, subfascial or submuscular is better for me? (Photo)

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