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The Subfascial Approach in Augmentation

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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, and capsule contracture was not felt to be a major problem.

This may be one of the secrets of the Meme implant, that is that they are firm to begin with, and therefore do not contract into a ball so easily like the softer implants do. In those early days, firmness was thought to be desirable to a certain extent anyway.

Then in a few years, in the late sixties, the patients were asking if something couldn't be done about the hardness, and softer implants were soon on the market. Then 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 now (since the 1980s) there are and have been many articles and opinions in the literature that the implants tend to remain softer in the submuscular position. The advantages of the subpectoral position are:


1. Dissection is just as easy as pre-pectoral position.

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 pre-pectoral, 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 a little softer.

8. The muscle over the implants provides a smoother, straighter contour from clavicle to nipple, without a demarcation line (especially as seen with capsule contracture) - no “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 have implants placed below the muscle.


The main disadvantages of submuscular implants are:


1. Anesthesia, especially local, is more difficult to achieve.

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 projection of the breasts forward.

7. The muscles may be visible over the implants when contracted, and press the implants laterally. This can usually be prevented. It occurs more frequently with an areolar 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 her.

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. If capsule contracture occurs and the amount of tissue covering the breasts is exceedingly thin, the condition will be more noticeable; a sharp demarcation line may occur at the superior margin of a spherical contracture, causing a stuck on, coffee-cup like appearance. The submuscular position can partly prevent this from happening.

If, however, the patient has considerable subcutaneous 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 often, such as with bowling, golf, tennis, swimming, etc., thorough counseling is needed to choose the best approach.


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  1984-2014 American Society of Cosmetic Breast Surgery  Last modified: May 22, 2014