Which would you recommend on a thin woman to get the most natural result?
What Are the Advantages and Disadvantages of Subfacial and Submuscular Placement? (photo)
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Doctor Answers 15
Subfascial breast implants preferred when possible
I'll disagree with my colleagues somewhat and point out that it's a matter of tradeoffs. It is the general thought by most plastic surgeons world wide that subfascial or subglandular implants offer a more natural result with less morbidity then submuscular implants. When you listen to the most experienced surgeons in the world who have done this operation for 30-40 years and have literally "seen it all, twice" , they by and large describe a personal shift toward smooth, round subglandular or subfascial silicone devices as it is the most forgiving operation with the least morbidity.
Outside the USA, it's much,much more common to place implants over the muscle. The caveats to that are 1) you need to go smaller with the implant & 2) you've got to have enough tissue to camouflage the upper implant. The issue of hardening of the implants is a little more complex then submuscuar or saline have less capsular contracture with more recent long term follow up of patients with implants. It's more accurate to point out that early hardening is more common but there is little difference between groups as you get further out. Very thin women with little tissue will require the coverage of the muscle and do well over time. Women with more tissue frequently get the implant staying high with the tissue sliding off the muscle within a few years (the "snoopy deformity") when placed totally or partially beghind the pectoralis
If that photo attached to the thread is your preoperative picture, I'd suggest you'd be an excellent candidate for subfascial placement
Pros and Cons of Above and Below the Muscle Implants
Implants placed below the muscle have more tissue above, is less likely to thin out the breast tissue and has a natural appearance at rest. It also has a slightly smaller chance of capsular contracture. However, when the muscle contracts during exercise, it will distort the appearance of the breasts which some women find disconcerting. There is also the possibility that he breast hangs over the implant if there is any sagging.
When placed above the muscle or sub glandular, a smaller implant can be used and will give a more visible result because the muscle isn't in the way. If properly sized, it can appear very natural because its in a more natural position and will not distort with exercise. However, there is a slightly higher chance of a capsular contracture and if its too big of the tissue then the breast tissue and skin can be significantly thinned out by the tension and pressure applied.
When properly sized and placed by an experienced plastic surgeon, both can give a natural result and have a minimal chance of complications. You should make clear to your surgeon what your goals are and how you would like your breasts to appear. Bringing photos of what you think you would like your breasts to look like helps. Although that exact look can't be guaranteed, it will help communicate to your surgeon better what you want.
Submuscular breast implants
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.
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Subfascial breast augmentation, the most misunderstood and best option or implant based augmentation
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.
The myth of Sub-fascial Implant Placement
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.
Location of Breast Implants
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.
Breast Implant Placement Above or Below the Muscle for Augmentation
A below muscle placement of a breast implant is a somewhat different technique then a decade ago. Below the muscle usually refers to "dual plane" placement where the upper portion is under the pectoralis and the lower is under the breast gland. The muscle gives more tissue cover to camoflauge implant characteristics. This gives a more natural appearance. A submuscular implant also causes less compression of breast tissue, making it easier to read mammograms.
Breast Implant Placement - Subgglandular/Subfascial VS. Submuscular
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.
Subfascial and subpectoral breast implant placement
The answer to your question is subpectoral. This is based on decades of experience and has not been significantly altered by subfascial implants compared to standard subglandular placement. The pectoralis muscle provides padding, protection, and naturalness for the upper half of the breast. It does not cover the lateral side or the inferior half of the breast (if properly released). This improves the look of the breast both short term and long term and has little downside or trade-off if properly done. Gel implants above the muscle can look natural if there is enough tissue coverage and they are sized properly, but this rarely holds up over the long term and eventually the implants will likely be visible in the upper part of the breast. Saline-filled breast implants above the pectoralis muscle will likely be visible even early on.
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.