Subfascial breast implant placement: still fashionable after all these years

Breast implants, New Study

Most patients (and most plastic surgeons) think of breast implants going either under or over the pectoral muscle. Under is the most common, and the dual plane method is considered standard by many. In actuality there are four planes for implant placement, and in my opinion dual plane may be the most problematic of them. New research confirms what I have thought for a long time: subfascial (pronounced like fashion, not facial) is here to stay.

Subfascial breast augmentation is a technique of placing the implant in front of the pectoral muscle, but there is more to it than that. The fascia is the thin but strong layer of tissue on the surface of the muscle. A space for the implant can be created on top of the fascia (behind the breast, or subglandular) or the fascia can be lifted off of the muscle, remaining on the undersurface of the breast. The idea is that although the fascia is thin, it is strong enough to add a little bit of support and smooth the transitions from the chest into the implant. Creating that smooth transition is one of the benefits of under muscle placement.

Does subfascial really make a difference?

Critics of the subfascial method are skeptical of how well this actually works, and whether it is worth the extra effort. But a recent study[i] from Brazilian plastic surgeon Ruth Graf finds a clear and lasting benefit to subfascial placement. I was especially happy to see this paper, because it was a presentation by Dr. Graf at an international plastic surgery meeting in Sydney Australia that got me started using the method almost 20 years ago. My own paper Subfascial breast augmentation: Theme and variations published in 2005 was the first on the technique in North America.

One of the variations is the split muscle plane, which I developed at the same time. This preserves the benefits of under muscle placement in the upper and medial (cleavage) area without the notorious animation deformities that can occur with dual plane. This is an important option because not every patient has enough “padding” of a fat layer under the skin to camouflage the edges of the implant. It is generally recommended that there is at least 1-1.5 cm (a little more than a half inch), determined with a simple pinch test. (A method called “composite breast augmentation” proposes to do fat grafting with subfascial placement in order to make it work for more patients.)

So subfascial is here to stay, especially as more and more patients show up with animation deformity from dual plane. I have performed well over a hundred cases of animation correction by converting from dual plane to subfascial or split muscle. (Examples here) It is equally gratifying to know that it can be prevented without compromising results.

[i] Graf, Ruth M. M.D., Ph.D.; Junior, Ivan Maluf M.D.; de Paula, Dayane R. M.D.; Ono, Maria C. C. M.D., Ph.D.; Urban, Linei A. B. D. M.D.; Freitas, Renato S. M.D., Ph.D. Subfascial versus Subglandular Breast Augmentation: A Randomized Prospective Evaluation Considering a 5-Year Follow-Up, Plastic and Reconstructive Surgery: August 11, 2021 - Volume - Issue - 10.1097/PRS.0000000000008384