Is subfascial breast augmentation a common placement?

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.

Breast Implant Placement

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.

Hi and great questions.

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!

Pictures would be very helpful in this case.  However, If you have saline sub glandular implants, I would certainly think that, in most cases, switching to silicone gel implants alone will almost always improve the quality of the result.  If you are lacking upper pole fullness, a wider implant may provide this for you.  Subfascial placement is an excellent first-time sub glandular pocket option that I perform often.  However, if you already have a sub glandular pocket, you probably cannot switch to a subfascial pocket at this time because the tissue layer will likely be too thin.  Switching to a sub muscular pocket is advisable if you are seeing rippling or having trouble with capsules, but otherwise may not be necessary..  

Thank you for this great (and concerning) question regarding subfascial breast implant placement.

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.

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.

Hi Mandeline, First, have no fear, the "high and tight" look with submuscular implants is usually only for the first few months until the muscle relaxes and accommodates the implants. This should be a very temporary concern. This method is far superior. When Breast Augmentation originally came about in the 1960s, all of these procedures were done over the muscle. Over time, surgeons realized that patients (up to 20%) were developing capsular contracture and by placing the implants under the muscle they could lessen this risk to less than 5%. A secondary benefit to going below the muscle is that the implant has more coverage over it, thereby somewhat camouflaging the implant’s edges. It is also easier to visualize the breast tissue on mammography since the muscle separates the breast implant from the breast tissue above it. Finally, there is a certain degree of support by the muscle that keeps the implant up, which is not found with the subglandular augmentation. The only downside for the patient is that there is generally more postoperative pain with the submuscular approach and the breast implants take longer to settle completely (approximately 3 months). For the surgeon, the procedure also takes a little longer than with the subpectoral approach. No, I do not know anyone doing subfacial implant placement. Just by design it doesn't make much sense. Fascial tissue is very fiberous and tough. It's in place to tightly bound you muscle with nerves and blood vessels. Trying to separate it from the muscle to even place the implant would be more trauma than I would be comfortable with for this procedure. If you've ever prepared chicken and had to pull off the thin, tough membrane on a chicken breasts, that's fascia! Even once separated from the muscle, it would be seemingly ineffective at giving the implant any support. Your cleavage is directly related to the shape and width of your chest and how close your breasts naturally are together. Adding more volume (bigger breast implants) will not necessarily increase your cleavage. If your breasts are naturally set wide on your chest, you will have more fullness after your augmentation, but not necessarily more cleavage. Firm implants indicate capsular contracture. Silicone implants are the gold standard for feeling more natural, but saline should not feel firm. Capsular contracture occurs when the scar tissue capsule your body naturally forms around your implants thickens, tightening around the implant. This may occur on one or both sides and may cause a shape change, discomfort, and may cause the breast to feel more firm. You may notice that one or both of your breasts are not as soft as they once were or may actually begin to harden, your breasts may begin to look or feel different, or you may experience some discomfort from the tightening of the capsule. The appearance of any of these signs should alert you to the need to have your breasts examined and your capsular contracture graded for severity. Early in diagnosis, contracture may be treated with massage and medications to help the scar tissue soften. In more advanced cases a revision surgery is needed, the most common procedure being a complete capsulectomy. This procedure involves removal of the entire thickened capsule surrounding the breast implant and replacement of new implants in a new breast pocket.I would recommend having an assessment in person with a board certified plastic surgeon and get their best opinion with recommendations. They will take measurements and explain the breast anatomy basics along with procedures and their limitations. Best of luck to you!

You have implant malposition. The implants have bottomed out. There are several reasons for this but weakness of the support system of the inframammary crease or violation of the crease during surgery can be one of the causes. This can be corrected in one operation by removing your implants and using a biologic mesh like SERI to support the implant and prevent a recurrence.

'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.

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.