Subfascial Breast Implant Surgery

  The subfascial placement of breast implants has many of the advantages of submuscular position without lifting the muscle attachments from the ribs.  The subfascial placement has become the preferred position for the placement of breast implants in our practice. The advantages and disadvantages of this position compared to above and below the pectoral major muscle are discussed. The clinical experiences with more than 1000 breast augmentations in the subfascial position are reported.  The indications for this technique are proposed. The incidence of complications are described from clinical experience and compared to other methods. The longest term of after surgery observation has been more than three years. The average time of observation of these cases has been about eighteen months. We have used the subfascial position through axillary, areola and inframammary incisions. As implants are placed routinely below the muscle through the umbilical approach, it can be done through that incision as well.

The subfascial position prevents the stuck on appearance caused by the interruption of the clavicle to nipple line just as the submuscular does. It is a little less potent in this because it is not as thick as the muscle.

The subfascial position prevents rippling above the areola just as the submuscular position does and probably as well.

The SF (subfascial) position does not push the implant down as the muscle does in the submuscular position (SM). This pressure of the muscle provides some hemostasis right after surgery. This force of the muscle also massages the breast implant and may help keep it soft. It also prevents the rising up and too early healing of the inferior breast pocket at the inframammary fold by the muscle pressure pushing down the implant against the area of the fold. It may help prevent capsule contracture by pressing the implant down. All these factors are logical and reasonable and clinically seem to be correct but are unproven and may or may not be important.

The subfascial is definitely less injury to the patient than the submuscular. It has less morbidity. The patient is less uncomfortable. Also it prevents the muscle movement that is sometimes visible after submuscular.

An endoscope is not necessary and is not routinely used for subfascial placement of implants in our experience.

Material and Methods

The subfascial approach was first done with axillary placement of the implant on one side unintentionally. Less rippling, visibility and palpability of the implant above the nipple was observed on the subfascial side. 

Originally when augmentations were first performed in the early 1960s with silicone breast implants they were placed in the subglandular position over the pectoral muscle.

They were hard. They were hard to begin with. If you look at the old Dow-Corning product descriptions of the implants, there were no soft implants in the early sixties. They were teardrop shaped, often with dacron patches on the back and they all became  hard, and were quite firm before they were implanted.

Since the early type implants were firm to begin with, they were expected to be firm. Only when softer implants were designed did capsule contracture become recognized as a major problem.

In 1967 C.O. Griffiths first reported the submuscular implant in augmentation. As the capsular contracture problem became more common with the softer implants, more surgeons shifted to the submuscular technique, until by 1980s there were many articles and opinions in the literature that the implants tend to remain softer in the submuscular position. 

The advantages of the subpectoral position compared to prepectoral or subglandular are;

1. Dissection is just as easy as prepectoral        

2. Bleeding is no greater        

3. Hemostasis is as easily obtained        

4. It is substantiated in the literature        

5. It is about as popular as prepectoral if not more       

6. The muscle over the implant reduces the feel of hardness if contractures occur.

7. The muscle movement presses on the implants and may thus keep them softer

8. The muscle over the implants provides a smoother straighter contour from clavicle to nipple without a demarcation line especially with capsule contracture – less chance of a stuck on look.

9. The muscle force pushes the implants down, counteracting the tendency of the capsule contracture to push the implants superiorly.       

10. The implants are further removed from breast tissue with less chance of being involved in breast diseases, lactation or breast biopsy.     

11. There may be less numbness of the nipples due to less damage to the third, fourth and

fifth intercostal nerves.

12. It is said to be better for mammography to be below the muscle.

The main disadvantages of submuscular implants are: 

1. Anesthesia, especially local, is more difficult.           

2. Post operative pain maybe greater.          

3. The muscle may be weakened.          

4. The muscle force may push the implant down too far.           

5. There appears to be less cleavage but this is debatable.          

6. Patients may have a flatter appearance with less forward projection of the breasts .

7. The muscles may be visible over the implants when contracted.   This can usually be prevented. It occurs more frequently with an areola  incision.

8. The breasts may not feel as soft or move as freely          

9. If capsule contracture occurs, closed capsulotomy is more difficult.

With all these different debatable considerations, one can see that there is no definite best way for all patients. Each patient’s special circumstances may determine which implant position is best.

For example, if the patient is very slender with very little subcutaneous or breast tissue covering the upper chest, the patient is a good candidate for submuscular implants because if  capsule contracture occurs, and the amount of tissue covering the breasts is exceedingly thin, it is more noticeable and a sharp demarcation line may occur at the superior margin of a spherical  contracture causing a stuck on, coffee cup like appearance that the submuscular position can partly prevent.

If however, the patient has considerable subcutaneous tissue and breast tissue to cover the implant, and is particularly desirous of cleavage, the submammary position might be  better. For the patient who is a professional or serious amateur  athlete who uses her arms, such as with bowling, golf, tennis, swimming, etc. in a professional or serious amateur sport, thorough counseling is needed to choose the best approach, and the submuscular may not be indicated.