Subfacial Placement Vs Under/Over Muscle

The surgeon I am considering does a subfacial placement rather than over or under the muscle. I can't find reports on subfacial augs. This doctor says because it takes longer and is harder to do. My concerns are rippling, sagging and my age. I had 2 other consults, one doctor told me I will sag terrible in 5 years and another said me my breast tissue was the most elastic tissue of my body and would have an amazing result. Opinions on subfacial and who to trust. Can I have a pretty breast at 55

Doctor Answers 21

Subfacial Placement Vs Under/Over Muscle

Probably more important than the specific procedure performed, will be selection of plastic surgeon. I would suggest that you spend most of your time/effort concentrating on careful selection of your plastic surgeon.

I think it is in your best interests (and that of most patients seeking breast augmentation surgery) to have implants placed in the “dual plane” sub muscular position. This positioning allows 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.

Best wishes.

San Diego Plastic Surgeon
5.0 out of 5 stars 1,461 reviews

Difference of Subfacial and Under/Over Muscle Implant Placement

#Subpectoral or #submuscular implants refer to placement under the muscle which still remains the most common placement in the United States. #Submammary or #subglandular implants are the placement under the breast tissue in front of the muscle.This tends to more common in Europe and South America.General guidelines suggest that women with larger drooping (ptosis) breasts that do not want a breast lift often have the implant placed above the muscle, although another option,#DualPlane, has become more popular. In the Dual Plane method, the implant is placed under the pectoralis muscle but the breast tissue is also release, in part, from the muscle. Those patients with minimal breast tissue should usually have the implant placed beneath the pectoralis muscle for more soft tissue padding. In any case, your plastic surgeon will determine which placement is best for you. When you come in for a consultation, the different options will be explained in further detail.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 106 reviews

Aesthetic Subfascial Breast Augmentation Performed Appropriately is Vastly Superior to Submuscular and Dual-plane Aesthetically

I will have to respectfully, but completely disagree  with previous responses.  Subfascial breast augmentation is VERY misunderstood.  Few surgeons perform this technique and many of those that claim to are really performing subglandular placement and making it sound fancy with the subfascial name.  Unfortunately many of those offering subfascial breast augmentations actually have no training in plastic surgery. 


I perform EXCLUSIVELY subfascial placement with a unique technique that I developed called "Cold-Subfascial Breast Augmentation.TM"  Most surgeons performing subfascial breast augmentation use a hot electrocautery device which kills and vaporizes a varying degree of the fascia which is the most important structure in successful breast augmentation in my opinion.  By damaging the fascia the procedure really equates to subglandular placement.  Keep in mind every surgery is very different in every surgeon's hands no matter what they call it.  It is what they actually do, their attention to detail and their level of aesthetic astuteness. It is true that the fascia is 1-2mm thick but it is also true that it has incredible tensile strength and that the advantages have been well studied and published by Dr. Ruth Graf and others.  In fact two months ago in Plastic and Reconstructive Surgery, the seminal journal of our specialty, A Turkish group published a clinical study touting the vast advantages of the subfascial plane.


My opinion is that the muscle should NEVER be violated in breast augmentation.  If you involve the muscle (ie dual-plane or submuscular placement) you Will get muscle jumping called animation( implants jumping around with arm movement), widely splayed unnatural appearing breasts( because the medial origin of the pectoralis major must be left intact and pulls the implants to the sides) and a "down and out" bottomed out appearance with time (because the bottom of the implant is subglandular with no support and the top of the implant is continually pushed down and out by the pectoralis major muscle.  In a true subfascial breast augmentation, the entire implant is held and shaped by a strong natural internal support bra- your bodies own fascia.  There are many surgeons placing foreign bodies like Strattice in womens bodies in failed attempts to create this support in revisions.  I say do it right and structurally sound the first time without foreign bodies and higher complication risks.


As far as recovery goes, most of the pain and swelling after breast augmentation is due to the muscle cutting and dissection.  In my experience patients are back to their lives in 1-5 days.  I commonly have patients fly in for surgery and most of them enjoy it as a five day vacation in Miami.  Some are enjoying poolside relaxation the next day and out for nightlife the next night.  Some linger at home for 5-6 days but this is by far the exception. 


With Cold-Subfascial Breast Augmentation I deliver what I believe to be unparalleled results as far as natural appearance and aesthetic beauty that I personally could never deliver with dual-plane or submuscular.  You will not find widely splayed breasts that jump around or have a down and out result in Cold-Subfascial patients.  I commonly revise dual-plane breast augmentations to Cold-Subfascial in the first year after a primary surgery because patients are embarrased by what has in my practice earned the name "The Miami Valley," the wide empty space between the breasts that you can commonly fit the palm of a hand.


To summarize the most important part of your surgery is not what the surgery is called but rather what the surgeon actually does.  There are many well respected dual-plane surgeons with many happy patients, I just have a very different aesthetic ideal , I am focused more on a natural look and patients looking for that tend to find me.  Others are looking for an "augmented look" which I flatly refuse to deliver making such patients not appropriate for my practice.  I hope this helps!



All the best,



Rian A. Maercks M.D.

Rian A. Maercks, MD
Miami Physician
4.9 out of 5 stars 72 reviews

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Subfascial breast augmentation

The sub-fascial approach has been presented at the Plastic Surgery meetings over the last few years.  To me, it's hard to understand how effective a very thin (less than 1 mm) layer of collagen - the muscle fascia - is going to make a difference compared to subglandular placement of the implant.  

The science behind the subfascial technique, proving some long-term advantages, is just not there yet.  As such, I would not recommend it to you (or anyone else) at this time....not until better long-term data comes in.


Best wishes,

Thomas Fiala, MD
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Subfascial Breast Augmentation

Pretty breasts at age 55:  Absolutely!  Your question was about subfascial versus submuscular augmentation.  Subfascial augmentation is performed between the lining of the pectoralis major and the muscle.  Submuscular augmentation is under the pectoralis major muscle.  Both are great approaches.  In order to be a candidate for the subfascial approach, you must have at least 2 cm of subcutaneous tissue to cover the implant.  Also, your request for implant size must not be too big.  The only implant that I would place in the subfacial region would be gel.  Saline may lose volume or ripple in this setting.  You are also able to have a smaller implant placed and have the same or similar effect as submuscular, so sag may be less.  The amount of sag is secondary to the size of the implant and skin elasticity, not necessarily subfascial versus submuscular. 

Jennifer Buck, MD
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Subfascial - really a subglandular plane - avoid it!

The pectoralis muscle is covered by a fascia, which is sort of fibrous sheet separating it from surrounding tissues. In the subfascial plane, the pectoralis muscle fascia is dissected off the underlying muscle and the implant can be placed in this plane.  However , this plane is very thin and I do not think it makes any difference from suglandular plane. I have not performed suglandular/subfascial breast azugmentation in 10 years. Not because I cannot do it (it is simpler than under the muscle ) but because submuscular plane have lots of advantages even in skinny girls. Firget about subfascual!…. 

Gregory Turowski, MD, PhD, FACS
Chicago Plastic Surgeon
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Subfascial versus subpectoral breast implant placement

I advise my patients to avoid all experimental procedures. As such, the subfascial technique is a new technique that hasn't been thoroughly evaluated. If this layer is thin, then it may not even provide much support to your implants. Additionally, this technique may not provide the benefits of submuscular implant placement which allows the pectoralis muscle to message your implants continuously and help avoid capsular contracture. I would recommend you get a couple more opinions prior to commiting to surgery.

Arian Mowlavi, MD
Orange County Plastic Surgeon
4.9 out of 5 stars 56 reviews

Breast Augmentation, Breast Enlargement, Breast Implants

Breast augmentation is an option for you.  You have many different choices when it comes to the augmentation.  The implants can be placed under the muscle or in the sub-facial location.  The implants can be placed in the sub glandular position also but this is done less frequently.  IT is more difficult to place the implants in the sub facial location.  If the surgeon has a lot of experience with this technique you will be fine.  You can expect to have good looking breasts for many years to come.

Jay H. Ross, MD, FACS
Palm Harbor Plastic Surgeon
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Subfascial approach better than simply above the muscle

Dear lady,

the subfascial approach simply means that the implant is placed just underneath the membrane which exists around the chest muscle. The advantage is that it gives more influence of the implant on the breast shape (correction of the drooping) because more superficially located, but has less chance of being visible or palpable at the edges.

In combination with a type of implants which is well attached to its pocket, such as polyurethane-covered implants, this gives a very stable result over time, and no increased risk of descending of the implant.

Alexis Verpaele, MD
Belgium Plastic Surgeon

Subglandular vs. Subfascial vs. Submuscular Breast Augmentation

As you can see, this is a highly debated question amongst experienced surgeons with each option having been recommended.  This debate is contested in our meetings and only in the past 5-10 years has the subfascial implant position been added to the discussions.  The fascial layer is of variable thickness in patients, but generally quite thin which makes its dissection fruitless at times; however, it has its proponents. For two reasons, I would recommend a submuscular implant position in your case.  First, the top part of your breasts are quite thin which would lead to implant visibility/rippling in that area if you chose either subglandular or subfascial positions.  Secondly, the incidence of breast cancer increases with age and for breast cancer surveillance the submuscular position is favorable.  You have pretty breasts now and you will be able to achieve the goal you desire without much difficulty.  Best wishes in your endeavor.

Luis Zapiach, MD
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These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.