Would you recommend subfacial or under the muscle placement? (Photos)

Question

Female, 39 years old, 121 pounds, height is 5’6. Skin type is very firm.

Paul E. Chasan, MD, FACS · Answer

Thank you for your question.  I have been in practice for over 30 years and breast surgery and revisionary breast surgery are a large portion of my practice.  Every decade a new group of young surgeons try to promote the subfascial breast augmentation.  If you look at the fascia of the pectoralis major muscle, it is thinner than tissue paper.  I often see patients make this mistake and end up with significant wrinkling in the center of the breast and also with time slide down of the implants down their chest wall.  I take care of very thin active women and figure and fitness competitors, and they do perfectly with a submuscular placement.  I would never recommend subfascial placement in a very thin person.  Best wishes to you.

Daniel Barrett, MD · Answer

Dear mrs.401 ,

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, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Ted Eisenberg, DO, FACOS, FAACS · Answer

I can only comment on under the muscle. Most women ask for a natural look. For years I have placed the implant partly under the chest muscle and partly under the breast (dual plane). I have done this in over 7500 women. My patients tell me that they are told their results look very natural. In fairness, I guess you would have to ask a surgeon who had that kind of experience with subfascial. Either way, I recommend an in person consultation with a plastic surgeon to discuss your goals and be measured. After I measure and discuss goals with my patients, we then look at pictures of women (my patients) with similar measurements with different size and style breast implants. They also get to see what they would look like when the breasts have fully dropped and fluffed and in clothes. You get to see actual results and the surgeon's experience and not a virtual idea of what can be achieved. Women tell me that this process is very helpful in determining what size and style breast implant is right for them. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

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.

Based on your photos alone, I would recommend submuscular placement so as to better camouflage the implant. In this regard, subfascial is not unlike subglandular.

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.

James N. Romanelli, MD, FACS · Answer

Dear mrs 401

Looking at your photos, I would recommend subfacial placement for you. You appear to have adequate soft tissue coverage, which is ideal for subfascial....this gives a more natural look and feel with easier recovery. Under the muscle can be beneficial for very thin patients with minimal breast tissue, but it comes with animation deformity when you flex your chest muscles. Subfascial Motiva Ergonomix implants provide excellent coverage and natural movement without the downsides of submuscular placement.

Best of Luck, Dr. Jim Romanelli

Michael Kreidstein, MD, FRCS(C) · Answer

My concern is the visibility of your scar from an inframammary incision.  Due to the tightness of your skin it is likely your new breasts will not hang over your scar to hide it.  I would recommend strong consideration of an axillary breast augmentation which is submuscular.  That isn't a recommendation of submuscular, but rather an emphasis on scar location.
Good luck!

Luis A. Mejia, MD · Answer

Hi, thank you for the question and pictures... in your particular case you do qualify for both procedures... you will improve drastically your breast area with ny technique

Camille Cash, MD · Answer

There are pros and cons to each implant placement.  Over the muscle implants have a little easier recovery since the muscle isn't involved.  They can provide a "rounder" look with certain implants.  Under the muscle tends to provide a more natural look as the upper portion of the implant is covered by the muscle adding a bit of camouflage.  The approach also comes with a lower risk of capsular contracture.  I've included a video about this process that I hope you find helpful.

Darryl J. Blinski, MD · Answer

Based on the post of photos, you have a symmetry of the breast to volume therefore, with such a thin chest wall needing implant coverage, sub muscular place would be indicated at different size implants. Best of virtual concert with expect fees to arrange from $5000-$10,000.

Would you recommend subfacial or under the muscle placement? (Photos)

Answers (9)

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