Teardrop implants: under the muscle?

There are
two choices for breast implant placement: sub-glandular (under the breast
tissue and in front of the chest muscle – the pectoralis muscle) or
sub-muscular (under or partially under the chest muscle). The best location
depends on many factors including: tissue thickness, weight, desired outcome,
and individual anatomy. Each position has advantages and disadvantages:Subglandular implant benefits:

A
shorter recovery time.

Less
discomfort initially.

No
distortion of the breast when the pectoralis muscle flexes.

Mild
preoperative sagging can be improved, especially if no breast lifting procedure
is performed.

Easier
surgical procedure.

Larger
implants can be placed. Subglandular
implant disadvantages:

The
implant may be more visible.

More
visible rippling, especially in patients with a small amount of natural breast
tissue.

Generally,
saline implants do not produce a good result in front of the muscle.

Higher
incidence of capsular contraction.

“Bottoming
out” in some patients.

Some
radiologists have more problems reading a mammogram with an implant in front of
the muscle. Submuscular implant benefits:

Usually
results in a better appearance for naturally small breasted women

Less
tendency for seeing ripples of the implant.

A
more natural feel to the breast especially in slender women who don’t have much
of their own breast tissue.

Less
interference with mammograms, although most radiologists take additional views
no matter where the implants are placed.

Lower
rate of capsular contraction.

Less
of a chance of “bottoming out” where the implant bulges at the lower aspect of
the breast and the nipple and areolas tend to appear excessively elevated. Submuscular implant disadvantages:

Recovery
usually takes a little longer and is more uncomfortable initially.

There
may be an “animation deformity”, which is a temporary distortion of the breasts
when the pectoralis muscle is flexed. Body builders and weight lifters
generally prefer implants in front of the muscle.

It
is harder to achieve cleavage in women who have widely spaced breasts.

The
implants often ride higher on the chest.

Actually,
most patients who have breast augmentations today have breast implants placed
in a combination or “dual plane” position. This approach has the same benefits
and disadvantages of a total “submuscular implant”, but with a lesser tendency
to ride high on the chest wall. The disadvantage as compared to a total
“submuscular implant” is a higher tendency for bottoming out.

The ideal
placement in any particular patient depends on their particular anatomy and
understanding of the pros and cons of each approach and desired outcome.

Keep in mind, that following the
advice from a surgeon on this or any other website who proposes to tell you
what to do based on two dimensional photos without examining you, physically
feeling the tissue, assessing your desired outcome, taking a full medical
history, and discussing the pros and cons of each operative procedure may not
be in your best interest. I would suggest that your  plastic surgeon be certified
by the American Board of Plastic Surgery and ideally a member of the American
Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are
comfortable with. You should discuss your concerns with that surgeon in
person.

Robert Singer, MD FACS La Jolla, California

Teardrop breast implants can be placed both above and below the muscle with very natural results. Your plastic surgeon may have recommended submuscular placement based on his experience working with shaped implants and his evaluation of your natural breast tissue. What’s more important than placement in preventing rotation, though, is your plastic surgeon’s skill in creating a pocket for the implants that isn’t too large. Although rotation is rare, you want the implants to fit snugly in the pocket without enough room to rotate. You may also want to talk to your plastic surgeon about low profile round implants that can give you a natural look without the risk of rotation.

Several of the most important reasons to go behind the muscle are to add tissue to mask rippling and to blend the edges of the implants so that they are less conspicuous.Since teardrop implants (specifically the Allergan 410) rarely ripple, and since their tapered edges blend well into the natural breast surrounding the implant, it seemed logical to conclude that they would do well in front of the muscle.The implant was first used in Sweden in 1993 and most of the first cases were in front of the muscle.  Rippling was not an issue.  Early results were great.  But after a year or two they were noticing that the tissue over the implant was thinning from the pressure of the implant and that the edges were gradually becoming more obvious.For that reason they soon switched to behind the muscle and that is the standard way that it has been taught since US clinical trials began in 2001.  I've done thousands of these over these past 15 years and with few exceptions have placed them behind the muscle.The purported disadvantages of going behind the muscle are illusory: there is not any more pain, cleavage can be created, and any amount of fullness in the upper breast is possible.  The only notable trade-off is that when you contract your pectorals muscles you will see some movement of the implant and even some traction on the skin in the lower inner breast in thin patients.  You need to be aware of this, but it is well worth the tradeoff in most situations.More specifically the current way to place implants behind the muscle is "dual-plane."  That means the surgeon decides exactly where and how much muscle coverage will best suit a particular patient and precisely performs the surgery to control the muscle in that position. "Half over/half under" are commonly used misnomers and have no basis in anatomy.