Breast implants - what are my options for implant placement?

Breast implant techniques have evolved over the last 30 years to accomodate the growing demands of patients for breast augmentation, and the need to improve surgical results. In general, most patients should undergo a submuscular implant. In terms of saline vs. silicone, the major determinant for a primary augmentation is the amount of breast tissue available to cover and camouflage the implant. If you are tissue deficient, as in a small A cup, saline implants will be more likely to be palpable as opposed to silicone implants.

I agree with those that say there is no single answer - every patient is different and you have to discuss your specific options with your board certified plastic surgeon. The only incision placement that has very limited benefit is the belly button and it can only be used with saline implants and may void any implant related warranty. Also think about it - where do most women expose more - their belly button or their breasts? Therefore, a scar on your belly button is more noticeable than one placed on your breast. Also, if you ever need a revision or if the implant needs to changed due to breakage - you can not use the belly button incision. And now you have two incisions. As for placement above or below the muscle or the dual plane positioning - most are dual plane but each patient is different and a detailed discussion with your surgeon is the best way to determine which method is ideal for you.

There are already a number of insightful answers to this important question. It has been stated that every patient is different and one technique is not always the right one for every patient. I agree 100%. Only after a comprehensive discussion about your desires and goals and a though exam can your plastic surgeon best discuss your options with you.

Michael C. Edwards, MD, FACS

Once the type of breast implant and the incision are determined, your plastic surgeon will discuss the optimal placement of the implants to create the best breast form. Classically these options have been either completely behind the muscle, called the submuscular breast implant position, or in front of the muscle, behind only the breast tissue. This latter placement is called the subglandular breast implant position. A third option, and the one that I often use in my plastic surgery procedures, is the dual plane breast implant position and combines many of the best features of the submuscular and subglandular breast implant positions.
The submuscular position for breast implants requires elevation of the pectoralis muscle, as well as some of the serratus muscle in order to have total muscle coverage of the breast implant. This placement has been thought to be the decreased risk of capsular contracture, or problematic scar tissue forming around the breast implant. Additionally the extra muscle coverage adds a layer of natural tissue over the breast implant in order to mask the ability to feel the implant. Unfortunately, women who have some substantial amount of breast tissue, and especially women who have some ptosis, or drooping of the breast tissue, can have difficulties with the placement of the breast implant completely behind the muscle. This is because the natural breast tissue can droop over the muscle and implant, causing a “double bubble”. The double bubble occurs when there is fullness on the chest wall from where the breast implant is being held up high by the muscle layers, while the breast droops down and creates a second, un-natural appearing fullness in a lower position, below the breast implant. This is a tell-tale sign of breast augmentation and a situation that your plastic surgeon should do everything he can to avoid.
The subglandular position for breast implants requires the breast implant to be placed over the muscle, and only behind the breast tissue. This can have a great effect on filling out the lower breast mound by adding volume to the area of the breast behind the nipple. Unfortunately, breast implants placed in this position have a slightly higher incidence of capsular contracture, and are more easily felt and seen without the muscle covering the breast implant in the upper portion of the breast. While the subglandular breast implant position may be a good option in some women who have minimal ptosis and a deflated appearing breast, the difficulties with this breast implant placement often preclude its use.
Here in Santa Barbara, I have found that the dual plane breast implant position, in many cases, combines the best of the submuscular breast implant position with the subglandular breast implant position. The muscle is released from its lowest origin in the inferior and lower medial portions of the breast area. The muscle is elevated in the superior aspect of the breast implant pocket, but the implant is allowed to rest behind the breast tissue in the lower aspect of the pocket where the muscle has been released. This allows the muscle to cover the upper breast implant and hide it from being easily seen and felt. At the same time, the dual plane breast implant position allows the implant to fill out the breast in the lower region, behind the nipple, to create a great teardrop shape and a natural breast appearance. Additionally, the muscle is able to massage the implant in the superior portion of the pocket, and thereby help reduce the problematic scar contractures that I want to avoid.