Implant position: Under or over the muscle?

A breast augmentation patient inquired yesterday as to whether it is better to place the implant above or below the muscle. The answer to this question depends very much on the individuals characteristics of the patient and the patient’s  desires. The simple answer from your potential surgeon of “that is the way I do all my breast augmentation surgeries” is not good enough reason to choose one route over another.

Generally the most important consideration in deciding if a breast implant should be placed above the muscle, referred to as a submammary breast augmentation,              ( click here or click here to view before/after submammary breast augmentation) or under/below the muscle,  referred to as a submuscular or subpectoralpectoral breast augmenatation  (click here to view before/after submuscular breast augmentation) is how much breast tissue is present and the quality of the that breast tissue. The only accurate method of determining the quality and quantity of each patient’s breast tissue  as it relates to  optimal implant position is by a thorough physical examination.  Pictures can not convey these important  physical characteristics.

Another factor in determining  optimal implant position is the activity or lifestyle of each patient. Sometimes compromises must be made in order to meet an individual patient’s needs. For example, placing an implant above the muscle in a female bodybuilder may lead to more implant visibility post operatively, but that may be less important than not having the implant move with muscle contraction as would be the case if the implant was under the muscle.

If there is not much  breast tissue present ,  an implant placed on top of the muscle has a  greater tendency to be visible. Being able to see the edge  of a breast implant is not a natural look .  Some patients actually want to have the pronounced appearance of the implant, the so called ” Pamela Lee Anderson” or ” Victoria Secret” model look. This generally refers to the roundness of the upper portion of the breast, but it the visibility of the edge of the implant which imparts this look. Also, sometimes an implant can wrinkle at some  point post operatively, usually months after the surgery. Placing the implant under the muscle allows for an extra layer of soft tissue coverage in order to  hide the implant  and therefore lessen the chance of visible wrinkling.  If the implant is placed under the muscle a slightly larger implant  may be utilized all other factors being equal. This is because along the medial border of the breast  (medial border being over the breast bone side versus the lateral border which is the arm pit side of the breast) there is considerably  less tissue.   Placing the implant  under the muscle  provides additional soft tissue coverage over the medial aspect of the breast and this can lessen the  chance of implant visibility post op.

An implant placed under the muscle may move with muscle contraction. There are  implant selection considerations and surgical techniques which can lessen the tendency for this to occur, but there is no getting around the fact that a submuscular implant may be prone to movement with muscle contraction.  If this does occur post operatively it is   generally minimal and well tolerated in most patients.

Also, if the patients tissue characteristics are poor (a lot of stretch marks, laxity of the skin) an implant placed on top of the muscle may not have the support as if it was placed under the muscle. In the long term , the skin can stretch and the implant drops significantly. This is known as a “ball in sock deformity”.  Imagine placing a cue ball in a tube sock…not a very pleasant visual; and very difficult to correct. Best to avoid this complication.

Also, in selected patients who need a breast lift with breast augmentation, placing the implant under the muscle can be safer in that the blood supply to the nipple area is preserved. If a more extensive mastopexy (breast lift)  procedure needs to be done to produce the most aesthetically pleasing outcome, this is an important consideration in order to avoid the potential complication of skin loss around the nipple region of the breast. Click here to view before/after mastopexy breast augmentation.

Placing the breast implant underneath the muscle also affords slightly more visualization of the breast tissue during mammogragphy. This might be a consideration in those patients who have a family history of breast cancer.

Are there down sides to having a subpectoral breast augmentation which have not been discussed?? of course…there is no free lunch so to speak.  Some of the other  downsides of having subpectoral breast augmentation include the following :  generally somewhat more painful post operatively, requires more time of restricted activity to allow for healing,  has  more swelling and  takes longer to achieve the end results of a naturally appearing breast than a submammary augmentation. All of the “down sides” are well worth it if the patient’s individual characteristic require subpectoral implant placement to avoid complications and undesirable outcomes.

So how do you know whether you should have your breast augmentation surgery utilizing the submammary or the subpectoral route? Start with a thorough examination and consultation by a qualified plastic surgeon who has extensive training and experience in breast augmentation surgery who understands  your needs and desires for breast augmentation which will maximize  your  individual  outcome.  Hope this has shed some light on submammary versus subpectoral breast augmentation. In the end,  the best route for breast augmentation is the one that will maximize your outcome.

 

Dilantin