Subfascial, split plane or submuscular for more natural look? (Photos)

New data shows that 'sub-fascial' has a greater risk of capsular contracture compared to sub-pectoral, and similar to over the muscle because it is over the muscle, and that paper thin fascia offers no protection or physical buffer of the implant. Please do not change pockets. So, what's the problem? Size, profile, and manufacturer. Size is an issue because you already feel too big, but also it puts a premium on upper pole fullness and projection. Profile is an issue because you've chosen an implant that puts its volume out in front. Manufacturer is an issue because Inspira implants were designed to look like saline. That's right. Their 'optimized' fill means there is no room for gel to travel without stretching the shell (requiring increase resistance) with any squeezing. This is the case even with the 'responsive' gel, which is the softest Natrelle offers. Sientra is the only manufacturer that offers highly cohesive gel with a 'sub-optimal' fill, leaving a little more room for low resistance movement. Your prior surgery also might be playing a role, as it looks like your surgeon did not adequately divide pectoralis muscle from its rib and sternal attachments, commonly the case with blind and blunt dissection via the axilla. I could be mistaken, and your surgeon may have used an endoscope and electrocautery, but it appears not enough was done. You should have a revision via an inframammary incision so that the necessary changes can be made to the pocket and smaller, flatter, and softer implants can be placed.

Good afternoon,
You have a common complication after transaxillary breast augmentation- animation deformity. I perform hundreds of revisions a year, and without a doubt the transax approach has the highest rate of revision. I put it in the category of "just because we can do something doesn't mean we should do something" and most advanced breast augmentation plastic surgeons have moved on to better techniques. You just can't see well enough to properly create the pockets from this tiny little incision under the armpits. You need your pockets fixed, and I would do this through a nipple incision.

If you want to minimize the animation deformity then you will need smaller implants. Since you want smaller breasts then this may be the best solution for you.

Best Wishes,

Gary Horndeski, M.D.

Dear Kuchajka,
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

The distortion you are experiencing with muscle contraction is animation deformity, related to the muscle detachment with the dual plane method. You can convert to either the split muscle plane or subfascial, in either case with muscle re-attachment. That will also allow the implants to be re-positioned a bit lower.

Your result is excellent. I wouldn't do a thing. Your animation deformity is mild. The implants are not too high. You will always be able to find someone to redo your surgery. You will spend plenty of money and might make your breasts worse.

You can have the implants placed in front of the muscle, but you may still have some animation deformity and you may see the edge of the implant. Long term, implants do better behind the muscle in most women. You can go down in profile and go with a smaller implant for less fullness.

The problems you are describing are not uncommon with the transaxillary approach. Any revision is going to need a breast crease incision.