While the issue of ‘over’ or ‘under’ the pectoralis major muscle receives a great deal of attention, even more important than implant position relative to this muscle is implant position vertically and horizontally on the chest wall. In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness.
In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that an implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear ‘bottomed out’, with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast – another situation with a distinctly unnatural appearance.
The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Breast implant pockets that extend too fat laterally will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. If the pockets do not extend far enough laterally, however, the result is an augmentation with an abnormal ‘side by side’ appearance. As it is the lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an ‘hourglass figure’, careful attention must be paid to ensure that lateral breast projection is adequate and appropriate.
Another consideration is that the implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient who is 5’2” will be inadequate for a large-framed patient who is 5’10”. Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast enhancement.
Michael Law MD
Board certified Plastic Surgeon
Raleigh, North Carolina