When placing a breast implant in the body, one big decision needed is do you place it in front of the pectoral muscle or behind it? The breast naturally sits in front of the muscle. In the early days of breast augmentation, all the implants were placed in front of the muscle. But when saline implants came on the market, and because of issues in some breast cancer reconstruction, there was a shift to putting the implant behind the pectoral muscle.
There has been a recent shift back to placing more implants in front of the muscle. Subglandular or “subfascial” (which is truly subglandular as the pectoral fascia on most women is a very thin layer) has become trendy. I recently saw a patient with subfascial implants and had rock hard implants at 1 year out.
Putting implants in front of the muscle has some advantages:
Subpectoral placement of implants has advantages:
There was a study published in Plastic and Reconstructive Surgery Journal May 2026, “Prepectoral vs Subpectoral Implant Based Breast Reconstruction: Evaluating the Shift.” The study was made as there is a trend in implant based reconstruction to placing the implants in front of the muscle. They stated during this time period placing the implant in front of the muscle went from 4% of cases to 90%. That is a huge shift in what is being done.
They concluded, “Implant plan preference reversed from 2018 to 2024. Despite certain advantages, prepectoral reconstructions showed 2x the risk of readmission and reoperation, including a 3x risk of reoperation for threatened prosthetic loss and ultimate failure.”
They did state that two stage reconstruction had lower complication rates than direct to implant reconstructions. (Direct to implant rates were 30% revision rate, though two stage had higher seroma rates.) They also state that ADM is used almost universally with prepectoral placement. Is it needed? Does it change the rates of issues? They state more studies need to be done.
This is one you need to weight the pros/cons for your goals. There is CLEAR evidence that going in front of the muscle, (aka subglandular, subfascial, prepectoral) has higher complication rates. This study reinforces that. When I met that patient who had capsular contracture within a year of subfascial placement, I did a deep dive into using mesh, ADM, and implants. One of the studies stated the best way to treat capsular contracture if the implant is in front of the muscle is to move it to behind the muscle.
I do most primary breast augmentations still behind the muscle. Not seeing rippling or wrinkling in the cleavage and upper breast is important. More padding is important. Lower biofilm (which leads to capsular contracture and breast implant illness) is important. Better imaging of the breast for breast cancer (which affects 12% of women) is important.
I just don’t think the fascia on the pectoral muscle is a hearty layer, so it isn’t protecting / separating the implant much from the breast. This means it likely will have higher biofilm rates. If I do the implants in front of the muscle, I absolutely put it behind the fascia.
Prepectoral versus Subpectoral Implant-Based Breast Reconstruction: Evaluating the Shift, Plastic and Reconstructive Surgery, May 2026
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