What is your opinion about subfascial placement of breast implants in breast augmentation?
I have been hearing a lot about subfascial placement of breast implants and the advantages over other placements. However, many doctors that I have seen in Arizona are either not aware of this placement or they do not recommend this placement for breast augmentation. Do you know why? Is it because it is a new procedure and if so, how new?
Subfascial placement has been popular in South America for several years, and I have been doing it for about 7 years. The fascia is a thin layer on the surface of the muscle, strong enough to contribute some support but not much in the way of "padding" so it is not an alternative to going under the muscle if coverage is needed. There is some debate as to how useful it is but I have found it to be a helpful option in many cases.
In my practice, I individualize as to what will make the patient look the best and for a long time. Implants placed under the muscle or fascia were placed there to either give the implant more coverage so ripples would be more minimized or to attempt to decrease the incidence of capsular contracture or hardness occurring. I have seen my patient many years after implants were placed under the muscle and have not liked that the breast has "fallen" over the mound of the implant. This I have corrected, but I have tried to explain to patients that this may occur as well as distortion and movement when the chest muscles are flexed.
Subfascial Breast Augmentation
Although many surgeons have claimed for some time to be doing a Subfascial Breast Augmentation, I personally believe it is more hype than real. The fascia is very thin and, even if it could be raised totally intact, it is not strong enough to contribute anything to implant stability or protection. I believe it is the total technique used that makes the difference. I place more than 95% of breast implants over the muscle and fascia, and I would put my results up against anyone else’s. They are soft and natural, the patients recover in 24-48 hours, and my re-do rate is less than 2%. These are the things you need to look for, not a specific technique.
This is a way to try and differentiate the operation as a marketing tool. Your local surgeons are not aware of it since it is not standard operating procedure. Go to someone who has done many, many breast augmentations; also determine if you like their before and after photos. Submuscular is my preferred approach, but subglandular is not out of the question.
Different surgeons have different opinions about placing the breast implant under the fascia of the pectoralis muscle. The reality is that pectoralis fascia is thin and does not amount to much tissue padding. On the other hand, elevation of the pectoralis fascia is relatively easy and can add an additional layer of tissue over the breast implant. I have placed breast implants above the muscle above and below the fascia, and quite frankly, believe the subfascial space is easier to dissect and maintain hemostasis. I still prefer to do the vast majority of breast augmentation under the muscle, but if there is a good reason to place the implant above, I usually go under the fascia. The most common reason to place the breast implant under the fascia has been in ladies who do a great deal of weight lifting or body building and want to preserve all their muscle strength.
Subfascial breast augmentation places the breast implant beneath a thin layer of fascia on top of the pectoralis muscle and beneath the breast gland. Purported advantages are that the procedure is less involved and less painful than sub-muscular breast augmentation but provides some advantage in terms of capsular contraction to sub-glandular breast augmentation.
In my experience the pectoralis fascia is so thin and often tenuous that in fact many sub-fascial breast augmentations in doubt being at least partially Sub-glandular and lose their benefit. In addition excess bleeding is common in my experience using this technique.
I no longer attempt subfascial placement but prefers sub-muscular breast augmentation and as many cases as possible.
The fascia is a very thin tissue that is between your chest muscle and breast tissue. It is thinner near the base of your breasts and gets minimally thicker as you closer to your neck. Many plastic surgeons don't consider it a very substantial coverage of an average sized implant so it really isn't much different than going simply above the muscle. I personally do not place many breast implants above the muscle because it is commonly believed this places you at a higher risk for capsular contracture and gives less coverage of the implant lending to a less natural look. Different plastic surgeons will have their own opinions so you would be best served by seeing a board-certified plastic surgeon who can examine you and give you their opinion as to what techniques will work best for you,
I hope this helps.
Michael C. Edwards, MD, FACS
President – American Society for Aesthetic Plastic Surgery
President - Clark County Medical Society
Anson, Edwards & Higgins Plastic Surgery Associates
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Las Vegas, Nevada 89113
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