Subfascial or under the muscle? (Photo)

Question

Should I do subfascial or under the muscle? The surgeon I seen told me if I did subfascial he would be able to put the implants closer together so I wouldn't have as much as a gap.

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation (“overs”):

•	Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster 
when compared to subpectoral augmentation.

•	Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).

•	Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.

•	Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.

Subpectoral Augmentation (“unders”):

•	Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.

•	Subpectoral implants have a lower rate of capsular contracture.

•	Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.

•	The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other.  As always, your board certified plastic surgeon can help guide you in your decision making process.

Daniel Barrett, MD · Answer

Dear jenifferslifestyle,
I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Gianfranco Frojo, MD · Answer

Under the muscle has clear advantages including lower rates of capsular contracture, less implant visibility/palpability, and a more stable result over time in general. I would highly recommend placing the implant below the muscle for those reasons and that you are relatively thin.

Sacha Obaid, MD · Answer

Hi there!  Implant placement will be decided on between you and your surgeon.  He/she will take into consideration the implant type and your breast measurements.  I have added a video in hopes that it helps to answer some of your questions.  Good luck!

Zeshaan Maan, MD · Answer

You can have excellent outcomes with either subfascial or submuscular placement of your implant. What will matter more is the skill and technique of your surgeon. 
The potential issue with submuscular placement is animation deformity, where the implant becomes obvious when you flex your pectoralis major muscle, for example when working out. Submuscular can also result in more pain during your initial post-operative period, though this can be variable. Personally, I favor a subfascial approach unless there is a compelling reason to go submuscular. Looking at your images, I don't see an obvious one.

William Andrade, MD · Answer

Hello, I agree that it is often feasible to put subfascial implants closer together than submuscular implants.  This is because if there is a large gap between where the pec muscles attach to your chest, the surgeon can't put the implants under the muscle and make them close together without detaching the muscle from your chest wall.  Fully releasing the muscle over the implants would negate one of the main benefits of putting the implants under the muscle, which is having a thicker layer of tissue over the implants.   The gap between the implants is an important consideration but there are many other advantages and disadvantages of these two pockets, such as different risks of implant rippling, palpability, capsular contracture, animation, etc.   All of these issues would be taken into consideration by you and your surgeon before deciding on the best implant pocket for your unique goals and body type.

Irena Karanetz, MD · Answer

Hello,

Thank you for the question.

Based on your photos, you appear to be a good candidate for subfascial (above the muscle) breast augmentation which can help bring your implants closer to the middle.

In addition, placing the implants above the muscle (subglandular or subfascial plane) can help minimize animation deformity (when implants move during weightlifting).  However, not everyone is a candidate for above the muscle breast implant placement because if the breast tissue are very thin, implant rippling may be more pronounced in the upper pole of the breast.

Implant size discussion and implant selection is one of the most important steps during your consultation with plastic surgeon. The decision-making process depends on patient’s desires, as well as breast and soft tissue dimensions.

I would encourage you to seek a consultation with a Board-Certified Plastic Surgeon to further discuss your options, specific techniques, concerns and expectations.

I hope this helps.
Best regards, Dr. Karanetz

Dr. Irena Karanetz
Breast Fellowship-Trained
Board Certified Plastic Surgeon

Gary M. Horndeski, MD · Answer

The fascia layer is very thin and most of the time is will tear. Your biggest issue is the nipple-areola complexes are very widely separated. You would benefit from a circumareola approach to reposition the nipple-areola complexes more medial. At the same time, small implants can be place submuscular.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Gerald Minniti, MD, FACS · Answer

As I've mentioned to you before, there is no logic in the concept of getting implants closer together with subfacial placement. Keep in mind that the fascia is a millimeter thick, and extending the dissection plane beyond the breast mound onto the sternal region will leave you rippling, the same as a complete dissection of the pectoralis muscle. At least with subpectoral placement, you have the benefit of thick tissue covering your implants. I think you are overthinking the gap thing and should realize you'll have a lovely result with subpectoral implants, with no one accusing you of having a large gap.

Joshua T Halka, MD · Answer

Subglandular or subfascial can definitely allow the implants to sit more medial on the chest, but in very thin patients, sometimes the implants can be seen at the top of the implant and you can even see ripples in the shell. 
If you have enough tissue at the top of the breast to adequately cover the implant then subglandular or subfascial can look great and give you a very round look with lots of upper breast fullness. Under the muscle often gives a more natural looking slope at the top of the breast, but it can be more limited by how and where the pec muscle attaches.
Hope this helps!

Subfascial or under the muscle? (Photo)

Answers (19)

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