I have subglandular saline implants right now, and have been told to get a more natural appearance I should go submuscular, but I don't like that high and tight look that most women have with the submuscular placement. What does subfascial mean? Is this a common placement? Would I benefit more with just staying in front of the muscle and switching to silicone? My implants now feel firm and are a little too far apart for my taste.
Subfascial Breast Augmentation?
Doctor Answers 13
Revision to subfascial for a beautiful natural shape
Subfascial placement is the only placement I use in my practice. Placing implants under the muscle causes spreading of the implants laterally and inferiorly creating a plateau between the breasts that is a dead give away of an augmentation. the muscle ends up pulling the superior pole down due to the baseline tome and does not enhance or bulk the superior pole at all in my opinion. I use a technique that is called 'cold-subfascial augmentation' that preserves the viability of this crucial structure and allows me to use low profile implants to create a tear drop shape with beautiful projection and superior pole slope. I would strongly recommend conversion to a true subfascial plane to prevent accelerated aging of your subglandular placement and to obtain a more natural beautiful shape. I hope this helps.
All the best,
Rian A. Maercks M.D.
Sub-fascial breast augmentation placement
'Sub-fascial' breast augmentation is possible. Fascia is the term for a sheet of connective tissue made of collagen, and the pec major has a fascial covering as most muscles do. Breast implants can be placed behind the pec major fascia only, rather than behind the entire muscle, however this approach is not widely used. The pec major fascia is a relatively thin layer of tissue, so it is not nearly as effective in concealing breast implants as the actual muscle itself. Partial sub-fascial placement can be useful in some breast augmentation revision surgeries, where variations in pec major origin or incorrect release of the pec major has resulted in significant distortion of breast appearance when the muscle contracts.
Subfascial implant placement: more marketing buzz than good medicine
First, let's talk about what fascial tissue is. It's the thin and very fibrous connective tissue that surrounds muscle throughout the body, including the pectoral muscle in the chest. Fascial tissue helps bundle muscle groups, blood vessels and nerves. Anyone who has ever skinned a chicken has seen fascial tissue. It’s that thin and amazingly stubborn layer of grizzly membrane over the muscle and meat. Similarly, in human anatomy, muscle and fascia are bound together. Attempts to separate the fascia and tissue to introduce an implant would be traumatic and ultimately ineffective.
When I review medical literature on subfascial placement (and there is very little - another warning sign) the supporting photo documentation often shows a pectoral muscle incision. The bottom line: the FDA, professional surgical associations, implant manufacturers and the vast majority of information in implant literature do not even mention subfascial as a viable breast implant placement option. Buyer beware.
While every patient and surgery is unique, Mandeline, your concerns do suggest submuscular might be the optimum placement option. As always, seek out only an experienced, board-certified plastic surgeon who can best deliver on the outcome you desire. I urge you to think twice about subfascial recommendations. It’s more marketing buzz than it is good medicine.
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Subfascial vs Submuscular Breast Implants
Thank you for your question. Subfascial Breast Augmentation can produce excellent results when done by an experienced Board Certified Plastic Surgeon who has used this technique.
However, in your case with existing Subglandular Breast Implants I agree that because of your previous Subglandular Implants fascial attachment to the breast has been disrupted and a Submuscular Breast Augmentation is a better option for you.
Submuscular vs. subfascial breast augmentation.
The purpose of submuscular placement is usually to camouflage the appearance of the implant, particularly in the upper pole. Having submuscular implants does not mean the implants will be "high and tight" unless the implants are totally under the muscle (which is uncommon). Typically, submuscular implants are in a "dual plane" with the upper 2/3's of the implant under the muscle and the bottom 1/3 under the breast gland. This allows for a more natural look in women with small amount of breast tissue. The subfascial plane was designed initially to capture the lower capsular contracture rates of submuscular implants, while keeping the same "look" as subglandular (no animation deformity). Unfortunately, if camouflaging the implants to create a more natural look is your goal, the subfascial approach does not add much to achieve this. I recommend having a few consultations with Board Certified Plastic Surgeons in your area to find out what would work best for you.
When to consider subfascial breast implant placement
I have used the subfascial plane for breast augmentation for more than 7 years. The fascia is a thin but tough membrane on the surface of the muscle, so that it can add support to an implant but not "padding" the way the muscle does. It is useful to avoid the muscle flexion distortions (animation deformity) that can occur with the dual-plane submuscular technique. However, when you have subglandular implants it isn't possible to go to subfascial in one stage, because for practical reasons the fascia has to remain attached to a surface - either the muscle as it is now with subglandular placement, or to the undersurface of the breast gland. So in that case going to submuscular or a split muscle technique makes more sense.
Sb-Fascial Augmentation and Advertising/Marketing Buzzwords
There are three different types of implant placement: above the muscle, below the muscle, or a combination (know as a dual plane). The correct placement depends on your goals and the appearance of your breasts. You need to be examined in order to decide on the best placement for you.
It sounds like you may have capsular contracture based on your current placement (sub-glandular), saline implants, firmness, and change in implant position. If you do have capsular contracture, then you will benefit from changing the position to sub-muscular and utilizing a textured silicone implant.
“Sub-Fascial” placement is different way of saying sub-glandular. The technical answer is that the pectoral fascia and the posterior breast capsule are essentially a fused structure; therefore, a sub-fascial placement is a sub-glandular placement. It is simply fancy marketing/advertising. If you do have capsular contracture, then a sub-glandular (aka sub-fascial) placement will not be adequate treatment.
I hope that helps. Best of Luck!
First of all, you ask a very good question. Subfascial placement of the implant basically means that the fascial layer (sort of like tendon material that covers the muscle) is lifted off the muscle to create a space. It is not always easy to elevate the fascia off the muscle and create a uniform space for the implant. Some surgeons believe that subfascial placement carries some of the advantages of submuscular position, like reducing the risk of capsular contracture (scar tissue around the implant distorting its appearance or causing pain), while preventing the implant from moving around when the muscle contracts, which is common in submuscular augmentations. However, since you already have a subglandular space, it may be difficult to obliterate, or seal off, the subglandular space if only the fascia is going to be lifted up. There would be a risk of the implant slipping out from the subfascial plane and back into the subglandular one. I usually perform subpectoral, "dual-plane" augmentation, which means the upper portion of the implant is in the submuscular position, but the lower portion is subglandular, allowing for a more natural, lower position of the implant and less of that high-riding appearance you are referring to. Silicone implants, in my opinion, tend to feel softer and more natural than saline, so I think that may help you as well.
An in-person consultation is critical to assessing your tissues, the implants and your aesthetic goals. But you can probably get significant improvement in your concerns based on your well-thought-out questions.
Good luck. Happy to help in any way.
Placement of breast implants
Under the Muscle (sub-muscular) – When you hear the words “under the muscle” this actually means the breast implant is placed partially under the pectorals major muscle. Submuscular placement may be more uncomfortable the first few days following surgery due to the disruption of the muscle. The possible benefits of submuscular placement are that it may result in less palpable implants, decreased risk of capsular contracture, and easier to image the breast with a mammogram. Under the muscle placement is recommend for women are are very thin with very little breast tissue. The partial muscle coverage will hide the implant better and help avoid visibility of any implant imperfections such as rippling. The appearance will also look more natural.
Over the Muscle (sub-glandular) – Over the muscle means above the muscle and under the breast tissue. This placement may make your surgery and recovery shorter and you will likely have less discomfort. This placement can provide a slight “lift.” Sub-glandular placement can result in more palpable implants, increased risk of capsular contracture and more difficult imaging of the breast with mammogram. This placement is often recommended for those patients with mild breast sag, but do not want a breast lift (mastopexy) and for tubular breast deformity.
Dual-Plane - This placement method is a more current technique most often used when there is mild breast sag and the patient does not want a breast lift. The breast tissue and muscle are partially separated to allow the breast tissue to sit in a better position. Dual-plane can be discussed further during the consultation should breast sag be of concern.
For women with moderate to severe breast sag, a breast lift (mastopexy) may be recommended to ensure the best result and longest lasting result. Failing to have a breast lift when necessary will only lead to a less than ideal result leaving the patient unhappy and needing a revision surgery. A larger breast implant can help lift the breast, but the low hanging breast tissue will still be present causing a disconnect between the implant and breast tissue located at the bottom of the breast.