Subfascial Implant Placement Risks?

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.

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.

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.

Hi! Subfascial placement is a reasonable option for some patients. The problems you list can best be prevented (or corrected) by meticulous dissection of a well designed new implant pocket.

Your particular anatomy would decide whether to use a subfascial or a subglandular (more common) approach. I don't think it is very important.

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!

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.

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.