Are subfascial implants prone to the same “rock in a sock” look that subglandular implants can acquire over time?

Question

I’m considering subfascial placement for my breast lift and augmentation, but I’m concerned about sagging. I have fairly lax skin from years of breastfeeding. Ive looked at a lot of before and after photos of subfascial augmentations, but they’re all a year or less out from surgery and I cant seem to find any that are 5+ years old. I’ve seen pictures of sub glandular augmentations with implants that look like socks in rocks, and I DO NOT like that look at all. Do subfascial placements usually hold up better over time? I understand that the fascia is quite thin. If any surgeons have any experience with this placement and how it holds up over time, I would be very grateful for any guidance.

Zoran Potparic, MD · Answer

You are right regarding longevity of results after subfascial breast augmentation; that is a technique that was popularized for many years by few surgeons but it is accepted in general use more recently. It does have some advantages over placement underneath the muscle but also some disadvantages. You should discuss these issues with your perspective surgeon in more details. Good luck.

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 faster 
when compared to subpectoral augmentation.

•	Subglandular 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.

Subpectoral Augmentation (“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.

Neither plane is immune to aging. A sub-pectoral result as it ages typically results in a mismatch between the higher implant position and the lower aging native breast. Subfascial/subglandular implants traditionally fall together which results in the "rock in the sock" effect. Regardless an aging result will often necessitate revisionary surgery.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other.  As always, your board certified plastic surgeon can help guide you in your decision making process.

Are subfascial implants prone to the same “rock in a sock” look that subglandular implants can acquire over time?

Answers (2)

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