Breast Implant Placement: 1, 2, Now 3 Choices

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After deciding which type and size of breast implant is right, the next most challenging decision breast augmentation patients need to make is about breast implant placement. Traditionally there have been two choices: placement under the glands or under the muscle. Now a third choice is emerging, one that’s both intriguing and controversial—subfascial placement.

Picture your breasts from a side view. In a subglandular placement, implants are located closest to the skin, under the fat and milk ducts that make up breast tissue. In a submuscular placement, the implants are positioned either partially or fully under the pectoral (chest) muscles, more deeply under the surface of the skin. That’s why many patients use the shorthand “overs” and “unders” terms to describe these two options.

Subfascial placement puts implants right in the middle of these two options. Muscle fascia, a thin sheet of connective tissue, covers and protects the pectoralis muscles just as it does many other muscles in the body. Some surgeons are promoting subfascial breast implant placement as a possibility for some patients as a way to potentially ease some of the drawbacks of the two tried and true placement options.

Placing breast implants in the subglandular position is fairly straightforward surgery. No muscles are cut, therefore recovery tends to be easier. But since less tissue covers the implants, there is a greater risk the devices will be noticeable, either because they project more abruptly from the chest wall and/or because implant edges and ripples may be visible. This is particularly true of women who are petite and have little body fat.

Submuscular implant placement is favored by many plastic surgeons as it creates a more natural look via a gradually-sloping chest wall. (Additionally, some believe there is less risk of capsular contracture, or shrinking and hardening of the breast pocket, with below the muscle placement.)

With these choices in mind, it may seem like a plastic surgeon and patient would be able to select the right implant placement for just about any given situation. But there is a group of patients for whom the choice is not so clear: women who are slim and athletic, especially professional athletes and body builders, whose goal is to gain curves that look and act completely natural.

Most times these patients do not want subglandular placement, as the lack of tissue to cover the implants would very possibly result in an unnatural look. But, when under the chest muscle, implants can look very strange when the pecs are flexed. In fact, some surgeons point out that the action of flexing strong pectoralis muscles over and over can eventually result changing the look of the implants at rest.

Try it yourself—bear down and flex your chest muscles. Now imagine a pliable implant inside your breasts. It’s easy to see that implants can look very odd indeed in these cases.

Enter the subfascial placement option. Plastic surgeons who favor it say that it adds a layer of coverage and support for athletic women who don’t want implants under the muscle. One surgeon in particular, Dr. Richard Baxter of Seattle, stated that he finds subfascial positioning to be “a reasonable compromise between the competing issues.”

Other plastic surgeons say that since the fascia is such a thin layer of tissue, it really can’t make much difference. And not only that, there are risks of tearing and bleeding of the fascia. These doctors believe that by paying extra attention to the size, type and positioning of implants, they can achieve a pleasing result for athletic women.

The subfascial technique is not brand new, but it’s new enough so there are few patients with track records to follow. If this is an option you think might be worth considering for you, extra research is in order.

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We value and respect our HERWriters' experiences, but everyone is different. Many of our writers are speaking from personal experience, and what's worked for them may not work for you. Their articles are not a substitute for medical advice, although we hope you can gain knowledge from their insight.