What Are the Advantages and Disadvantages of Subfacial and Submuscular Placement? (photo)

Question

Which would you recommend on a thin woman to get the most natural result?

Rian A. Maercks, MD · Answer

Subfascial augmentation is a very misunderstood procedure.  Those that are inexperienced or ignorant say it is a farse or the same as subglandular, but this is the farthest thing from the truth.  Subfascial is the only technique that can provide true shaping support from within the breast and maintain a dissociation from the pectoralis major muscle minimizing implant movement of 'animation.'

	 

	I find the fascia so crucial in creating a beautiful breast shape that I developed something called the 'cold-subfascial augmentation' which preserves all of the fascia and allows precise shaping of a breast to fit the individual patient.  Dual plane implants are plagued by lateral displacement, bottoming out and muscle jumping or animation.  I hope this helps!

	 

	All the best,

	 

	Rian A. Maercks M.D.

Austin Hayes, MD · Answer

It's a great question. I strongly prefer under the muscle implants because the muscle provides another layer of camouflage for your implants. The muscle contours the top of the implant to give it a more natural slope and hide rippling of the implant. Implants under the muscle have a decreased risk of scar tissue forming around the implant (capsular contracture).  Also, breast cancer screening with mammography gives better images of breast tissue when implants are placed under the muscle. Although an implant on top of the muscle can be a good choice for some women, for very thin women there is not enough camouflage for the implant to look natural. When considering breast augmentation make sure you find a board certified plastic surgeon who will take the time to answer all of your questions and explain all of your options, so that you can decide if breast augmentation is right for you.

Larry S. Nichter, MD, MS, FACS · Answer

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

Armando Soto, MD, FACS · Answer

Hi there-

	The superficial pectoral fascia under which implants are placed in the subfascial approach is so thin that over the long term there is little difference between this technique and subglandular placement. 

	In other words, the average woman desiring breast augmentation is best off with sub-pectoral placement. Even when the immediate outcome of subglandular or subfascial augmentation is pleasing, it is not as long lasting, and inevitably deteriorates much faster due to the relative lack of support for the implant.

Steven L. Ringler, MD, FACS · Answer

The most popular technique for breast augmentation in the U.S. at this time is submuscular placement of the implant. The reason for this two fold. The first being a much lower rate of capsular contracture (scar tissue tightening around the implant), and secondly, a more natural contour to the upper portion of the breast. Subfascial placement of the implant most often refers to implants that are placed behind the muscle in the upper portion of the breast and are not completely covered by the muscle in the lower portion of the breast. This may also be referred to as "dual-plane" technique. Originally implants were placed in the sub-glandular plane (between the breast tissue and muscle fascia), however, this technique may result in more visibility of the edge of the implant and has a higher rate of capsular contracture. Some surgeons attempt to place the implant totally under the muscle fascia ( a thin layer of connective tissue on the surface of the muscle), however, this technique may only reduce contracture rates, but not improve the contour of the breast as much as the submuscular approach. The main disadvantage of sub muscular placement is implant movement with muscle contraction (animation) which might be disturbing to some people.

Tom J. Pousti, MD · Answer

Thank you for the question.

	In my opinion,  there are numerous advantages of sub muscular (dual plane) breast augmentation. This  implant positioning will give you the best long-term aesthetic results and reduce the chances of complications such as significant rippling/comparability/ encapsulation and interference with mammography.

	Best wishes.

Michael Law, MD · Answer

This may be a somewhat controversial statement, but in my opinion there currently is really only one acceptable position for breast implants in an elective cosmetic surgery patient: behind the pectoralis major muscle (sub-pectoral augmentation). There are a number of very compelling reasons to place implants behind the pec major, and the most compelling one of all is the fact that radiologists report that the mammographic imaging of breasts for the purpose of breast cancer screening tends to be more easily accomplished when breast implants are sub-pectoral (compared to pre-pectoral, also referred to as the 'sub-mammary' position). An American woman's current lifetime risk of breast cancer is approximately 1 in 8 to 1 in 9, so the issue of breast cancer screening must be taken very seriously. Mammography is by no means a perfect screening study, but it is the standard of care at this point in time. The most sensitive and specific test for breast cancer is a contrast-enhanced MRI scan, and breast implants do not impair breast tissue visualization by MRI.

	The next very compelling reason to select sub-pectoral placement is a cosmetic one. Implants placed on top of the pec major tend to stand out in the upper pole of the breast, creating a rounded, convex and distinctly unnatural-appearing breast profile. With implants in a sub-pectoral position, the upper pole of the implant is flattened somewhat by the muscle, helping to create a smooth transition from the area in the upper chest where the breast begins, and a gradual slope towards the nipple that is not excessively rounded or convex. In some patients with a fuller breast volume preoperatively one may get an acceptable appearance with pre-pectoral placement - initially. The problem is that as breasts age, the fatty tissue atrophies and breast tissue thins out, and the area where this is most obvious is in the upper pole and cleavage area. So a pre-pectoral implant that was initially well-concealed may, after a few years, become painfully obvious (including visible implant folds and ripples) in the upper pole.

	'Under the muscle' and 'sub-pectoral' are actually somewhat misleading terms, as in most cases the implant is only partially subpectoral. The anatomy of the pectoralis major muscle is such that it is actually just the upper/medial half of the implant that is covered by the muscle, while the lower/lateral half of the implant is submammary. The pectoralis major thus provides an additional layer of tissue to conceal the implant in the most cosmetically significant area of the breast: the cleavage area. This is why saline implants are often easy to feel laterally, as they are covered by breast tissue only in lateral aspect of the breast, and in slender patients who have small breasts preoperatively the implant is often immediately under the skin in this area.

Darryl J. Blinski, MD · Answer

Much differing opinions. It is a personal decision. Most in US use sub muscular or sub fascial placement. I would also point out on your posted photos you have an asymmetry that also should be discussed. Best of luck.

Peter A. Aldea, MD · Answer

There is NO ideal breast implant. All of them are essentially sophisticated silicone bags in various shapes and sizes filled with either salt water or silicone gel. When placed on end (the way they sit in your chest) - THEY ALL RIPPLE (gel-filled less than saline filled). As a result the more tissue we can put on top of the implant and cover the ripples, the more attractive the result.

	Since the vast majority of women have an augmentation because they do NOT have a large amount of breast tissue in the first place, most women do NOT have a sufficient breast tissue available in the first place, most of them would look better and avoid the "rippley ridges look" along the top of the breast by placing the implants under the muscle.

	As regards the FASCIA of the pectoralis major muscle, it is paper thin and provides no effective advantage over the placement just under the gland. In my opinion this option is offered as a gimmick to differentiate one self in a tight economy rather than being based on  real advantage.

Steven Wallach, MD · Answer

In general there are two choices: partial submuscular( dual plane) or subglandular. Subfascial is really similar to subglandular because the fascia is extremely thin and I believe that it does not offer any added benefit to the subglandular approach.

What Are the Advantages and Disadvantages of Subfacial and Submuscular Placement? (photo)

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