Subfascial Implant Placement Risks?

Question

What are the risks for Capsular Contracture, Symmastia, botttoming out, and distortion with subfascial placement? Are they better or worse? I'm interested in changing my unders to overs (because of severe distortion), but want to know more about the subfascial placement.

Rian A. Maercks, MD · Answer

I agree with the previous surgeon's response.  Although I am a huge proponent of subfascial placement of breast implants and taking extra steps to preserve this fascia in my 'cold-subfascial technique the surgeon is the most important piece of the puzzle.  If the surgery is not executed well then it really doesnt matter what you call it.  For example there are practitioners that use terms such as subfascial as a marketing ploy and either destroy the fascia with dissection technique or electrocautery ar just ignore the fascia completely, delivering a subglandular placement.  A well trained, technically gifted plastic surgeon with grounded judgement should be able to deliver excellent results with any technique they are comfortable.  Although I do believe subfascial placement is the ideal technique and has greatly reduced risks of all complications that you mention, certainly a patient is in better hands with an excellent surgeon and conventional techniques then a poor surgeon with advanced techniques.  

	 

	All the best,

	 

	Rian A. Maercks M.D.

	 

	All the best,

	 

	Rian A. Maercks M.D.

Peter J. Capizzi, MD · Answer

Sub-muscular implant placement is almost always the best choice. The muscle is most important as it provides an additional layer between the implant in the upper breast area. It camouflages any rippling that may occur and provides another plane to make it easier for mammography. Submuscular placment also lowers capsular contracture rates. Subfascial placement is more marketing buzz than sound medicine. Good luck to you.

Otto Joseph Placik, MD · Answer

The Fascia can be a delicate structure which can be difficult to raise intact.
Commonly, when we perform breast reconstruction surgery after a mastectomy, the facscia is destroyed and we need to reuild it. This is one of the most commonly performed breast reconstruction technique. However, we continue to place the implant under the muscle, but reconstruct the fascia over the lower half of the breast, where it is particularly thin.
In augmentation patients, the fascia also becomes this over the lower and outer portions of the breast and technically, the pectoralis fascia is discreet from the serratus fascia.
The muscle is a clearly definable large anatomic structure whereas the fascia is less defined.
Similar discussions are held with buttock implants due to the size fo the gluteus muscles. However, repeated pistoning of an implant with exercise or activity can thin the fascia in this location.
Because the Subfascial implant placement is not widely practiced, it is difficult to draw any meaningful data from research published to date.
According to my references, approximately 80% of surgeons place their implants under the muscle.
Due to the tenuous nature of the fascia, I see it as a better alternative to subglandular placement, but generally believe the submuscular position offers best option. It is also important to note that is the position generally preferred by radiologists when interpreting mammograms as it results in the least distortion or obstructed visualization of the breast tissue.

Richard Baxter, MD · Answer

Your question is a very good one. The subfascial technique is something I have been doing for 6 years and more than 400 cases. It is still uncommon in the U.S. but widely used in South America, Canada, and other countries.
The fascia is a thin but tough layer on the surface of the muscle, so it can be used for support of the implant but it isn't thick enough to add "padding". There are some variations that help with this while still correcting the distortion that occurs with muscle activity. If you like, I can send you a copy of my article on the subject.
Capsular contracture occurs in the same percentage of cases as under the muscle in my experience, and problems of malposition such as bottoming out are actually less common because one of the causes of that is the muscle pushing the implants down when they are under. I have had no cases of symmastia with the subfascial technique.
Please contact me if you would like a copy of the article or have any other questions.

Nodas Kapositas, MD, PhD · Answer

I am doing subfascial breast 
augmentation in most cases since 1999.Subfascial breast augmentation 
actually leads to optimal results especially in women more than AA and B
 cup size and when we  select the most suitable size of implant under a 
meticulous hemostasis and creating the right size pocket under the fascia with a long and thin cautery no-touching  the breast tissue.We are able to work with two types of implants 
cohesive I and II Mentor,USA (no finacial benefits) according to breast 
elasticity and the breast  tissue amount .We have 
achieved a very good  and long lasting results and our capsular 
contracture rate is very low.This type of breast implant placement does
 not create any bottoming out and or any distortion.In terms of the results i
 do believe that create the most natural appearance of the new breast either when someone 
touch the breast or the way the breast look under the bra.

Robert Oliver Jr., MD · Answer

I am a big fan of this technique in patients  with enough upper pole tissue thickness to cover the implant. The availability of form stable devices has opened the potential for this placement to more women as they ripple less. For a round implant, the Sientra textured implants are my preferred choice as they resist rippling while being less likely to harden. I strongly disagree with the suggested trans-axillary subfascial placement of silicone implants as 1) the scar is large and frequently visible 2) the rate of implant hardening is higher (presumably from more skin bacteria in the armpit coloniziuing the implant)3) implant malposition rates are clearly higher with this approach in most people's hands

Steven Wallach, MD · Answer

Sub fascial implant placement is a position for breast implant placement that is being done by some surgeons around the country. I don't understand the interest in it. The fascia over the muscle is extremely tin and it doesn't offer any significant additional coverage than a subglandular placement. If you want more coverage a submuscular pocket is better. There are nor studies that I know of that reports on long term complications with this approach.

Kenneth R. Francis, MD, FACS · Answer

dmchez,
The risks that you mention are probably the same for almost all breast augmentation techniques and are very small. The submuscular plane seems to have a slightly lower incidence of capsular contracture. Symmastia and bottoming out are mostly surgical technique-dependent and not plane of placement.
I would first ask why you are interested in changing your implant location? The submuscular plane is probably the most preferred by surgeons and patients alike.  Developing a plane between your fascia and muscle may be difficult, and perhaps even impossible in light of your previous submuscular dissection, which by the way, is often subfascial in its lower hemisphere. Good luck!

William B. Rosenblatt, MD · Answer

I have been doing breast implant surgery for over 30 years. In that time, I have put implants over the muscle, partially under the muscle, and completely under a muscle layer (only for breast reconstruction). The layer of fascia over the muscle is so thin and attenuated, that I have never seen or done a case where I could say it was sub-fascial. The fascia tears and fragments and you end up with an implant that is esentially over the muscle and under the breast. There is no difference in capsule contracture or other complications.
If you find that someting is done only in another country, one must ask themselves why.
My answer is that it is not a real operation, at least in my hands and with my 30+ years of experience doing breast surgery.

James C. Grotting, MD, FACS · Answer

I assume you mean by unders to overs, you are talking about your breast implants in relationship to the pectoralis major muscle.
The subfascial plane is immediately superficial to the muscle, but underneath the pectoralis fascia. Many clinicians feel that this added layer of support is beneficial in decreasing the chances of negative sequelae, such as rippling and implant malposition. 
The frequency of the postoperative problems you list has more to do with the experience of the surgeon than the technique selected. Subfascial placement of breast implants is a reasonable technique, that likely provides more coverage and soft tissue support than the traditional subglandular (above the fascia) technique.

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