Submuscular Vs Subfascial and Periareaolar Vs Inframammary?

I have been to two consults for a breast augmentation and have had varying opinions on implant placement and size. I am stuck between one doctor who wants to do a subfascial placement and periareaolar incision vs another doctor who would prefer a submuscular placement with an inframammary incision. I am a 34 A wanting the most natural look and feel possible but will not sacrifice the ability to breastfeed or risk complications (rippling/capsular contracture) down along the line. Please help!

Doctor Answers 5

Sub muscular vs Sub Glandular placement

Submuscular placement may be more uncomfortable the first few days following surgery. The possible benefits of submuscular placement are that it may result in less palpable implants, less capsular contracture, and it will make it easier to image the breast with mammography. The appearance may be more “natural” for patients who are very thin. Subglandular placement may make your surgery andrecovery shorter and you may have less discomfort. This placement may provide a slight “lift”. Subglandular placement may result in more palpable implants, more capsular contracture and more difficult imaging of the breast with mammography. This placement is often recommended for those patients with sagging, but do not want a breast lift (mastopexy) and for tubular breast deformity

Orange County Plastic Surgeon
4.9 out of 5 stars 154 reviews

Implants location and incisions

I prefer to go either periareola or unframammary and that depens upon the size of the areola nad the type of implant. Ad for pocket, I do not htink the subfascial approach offers anything more than being subglandular, and in ost of my patients who usually are very thin, submuscular give more soft tissue coverage superiorly.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 28 reviews

Breast Augmentation and Differing Opinions?

Thank you for the question.

As you have noted, if you ask 5 plastic surgeons for their opinions, you will receive at least 7 opinions. Different plastic surgeons will give you different opinions based on their training, experience, and personal preferences. This range of opinions you will receive will potentially be confusing.

You should be aware that the complications that you mention are possible  surgeon's best efforts and regardless of the breast implant positioning. I still think it is in your best interests (and that of most patients seeking breast augmentation surgery) to have implants placed in the “dual plane” sub muscular position.  This positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look  of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability  of the implants (which may increase with time, weight loss, and/or post-pregnancy changes).

The submuscular positioning  also tends to interfere with mammography less so than in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position.

I would suggest that you do your due diligence carefully and choose your plastic surgeon wisely.  Then allow him/her ( after you have communicated goals clearly with him/her)  to choose the breast implants,  surgical approach and breast implant pocket that will best meet your objectives. 

In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural” or “C cup” or "side boob" etc means different things to different people and therefore prove unhelpful.
 Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also be inaccurate.

I use  intraoperative sizers and place the patient in the upright position to evaluate breast size. Use of these sizers also allow me to select the breast implant profile (low, moderate, moderate plus, high-profile) that would most likely achieve the patient's goals. The patient's goal pictures are hanging on the wall, and allow for direct comparison.
 I have found that this system is very helpful in improving the chances of achieving the patient's goals as consistently as possible.

I hope this helps.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,487 reviews


I think it is a good idea to visit several plastic surgeons, but you will get differing opinions if you do. In a slim patient who is looking for a natural look I recommend silicone implants.  The choice of incision site is up to you since there will be a permanent small scar.  I let patients decide but there are advantages and disadvantages to each.  In patients who may want to breast feed I do not recommend the periareolar site.  I tell my patients that the most straightforward way to do the procedure is with the inframammary incision.

Most plastic surgeons place the implants under the muscle which is what I recommend especially in slim patients. The disadvantage of subfascial or sublgandular is less tissue coverage over the implant and a greater chance of feeling or seeing ripples which can occur even with silicone implants in slim patients. The submuscular position also has the lowest risk of capsular contracture.

Thank you for your question and best of luck.

Ralph R. Garramone, MD
Fort Myers Plastic Surgeon
4.8 out of 5 stars 59 reviews

Under the muscle vs subfascial placement

As most of the data shows that submuscular placement has the lowest rate of capsular contracture, this is probably still your best option if capsular contracture and rippling are your primary concerns. This is particularly the case if you are very slim. Subfascial placement is really just subglandular placement, and I am not sure what the fuss is about as it is the only way to perform this procedure in my opinion. Subglandular works well for individuals with larger breasts and thicker tissues.

The advantage of subfascial placement is the ability to place the implants closer together for more cleavage and less separation of the implants due to the action of the muscle. If you are slim and planning saline implants, then you should be very careful about subfascial placement. Gel implants are the only option in slim patients for subfascial placement

There are pros and cons of both approaches, but in general in slimmer patients, submuscular placement is a safer bet. For these patients who are very slim, but want more cleavage, I am combining submuscular augmentation with fat grafting - otherwise known as the cleavage aug or composite breast augmentation.

Jeffrey Hartog, MD
Orlando Plastic Surgeon
4.5 out of 5 stars 60 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.