Options for Breast Implant Placement?
Doctor Answers 24
Breast implants can be placed in several different...
Total submuscular placement implies complete muscle coverage. This is not feasible with cosmetic breast augmentation since the pectoralis (chest) muscle inserts on the ribs above the bottom fold of the breast. Thus, in order to get the breast implant low enough on the breast to reach the inframammary fold, the muscle attachments to the low ribs must be released; which in turn creates a partial subpectoral pocket.
Additionally, the lateral aspect of the breast implant is usually not covered by muscle as well since the muscle comes across the breast at an angle from the shoulder to the middle of the chest in a fan shape.
- The only time an implant is truly completely submuscular is in cases of breast reconstruction for mastectomy when the lateral chest wall muscles are elevated to cover the implant.
- This is not used in cosmetic breast augmentation because this added dissection leads to too much discomfort afterwards.
- This is the most common breast implant placement pocket, especially for saline implants.
- It is used widely for patients that do not have a lot of coverage at the top of their chest to help hide the implant.
- The dual plane position makes the recovery more painful than a more superficial plane. Additionally, some patients can be unhappy with distortion of the breast and nipple with contraction of the muscle.
The FDA reports that mammogram may be more accurate in this position as compared with the subglandular or subfascial pockets. However, many radiologists disagree with this blanket statement and feel that mammography is equally impaired by breast implants in any plane. These radiologists suggest that the presence of capsular contracture (thickening of the tissue around the implant, making it firm) actually causes the worst impairment of mammography regardless of the position of the implant.
The subglandular pocket is directly under the breast gland.
- This was a very common pocket used for silicone implants since they were first introduced in the 1960s.
- The pocket has advantages of a less painful operation and no distortion of the breast with contraction of the muscle.
- In thin patients, there is a risk of implant wrinkling and rippling.
- This thick coating helps hide the edges of the implant, especially at the top and middle of the chest where the skin gets thin.
- This may cut down on visible wrinkling and rippling.
- There may be a slightly higher rate of capsular contracture in the subglandular and subfascial planes in older breast literature, but recent studies seem to suggest that the rate is equivalent.
Breast Implant Position
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.
Breast Implant Placement Important Considerations
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.
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Options for Breast Implant Placement
There are 3 traditional approaches for breast...
- Under arm (transaxillary)
- At the junction of the pigmented skin of the areola and breast skin (periareolar)
- Under the breast at the fold (inframammary)
Each incision has its advantages and disadvantages, as well as the ideal breast for which it was designed.
- Transaxillary, under arm, approach is good for small breasted women with small areola and no significant breast fold.
- Periareolar, junction of the pigmented skin of the areola and nonpigmented skin of the breast, approach is the most versatile approach, as the incisions heal very well and are hidden by the color change of the skin. This incision is also part of every breast lift technique if a lift is needed at the time of the augmentation.
- Inframammary, breast fold, approach is ideal for women with enough breast tissue to hide the breast fold when standing. In this situation the incision will not be visible to you when standing.
Breast implant position
Under the muscle has many other disadvantages such as severe post-operative pain, but there are no advantages that I can discern after using both positions for over 30 years. In addition, placing the implants over the muscle does not require general anesthesia.
Patients have many potential options in the selection of...
Patients have many potential options in the selection of the proper breast implant for their own optimal result.
Of course, working with an excellent and experienced plastic surgeon is essential and your surgeon should carefully explore what kind of size increase and upper pole profile look you feel would be best for you. Following this, a careful dimensional measurement of your chest wall should put you and your surgeon into the area of the implant catalogue where the diameter of the implants match your own diameter well.
The volume of the implant just follows along with the diameter that best suits you, so don't get hung up on the volume because the diameter is actually more important in getting you the right implant. The profile of the implant determines the "look" in terms of cleavage and upper pole fullness. The "moderate" profiles look the most natural while the "moderate plus" and "high" profile implants are designed to create greater cleavage beyond what would be natural.
Silicone gel implants are selected by patients who place a high priority on the "feel" since they feel more like natural tissue. Saline implants are selected by patients who believe they are "safer" and feel more comfortable with them and are willing to be able to detect the edge of the implant laterally and not have that bother them.
Round shaped implants, both saline and gel, work better for augmentation because the tear drop shaped implants don't always heal symmetrically and they can therefore look very different from each other and require more surgery for correction.
Incision location and implant placement
There's a lot of great information here and I agree with 95% of it.
In my San Francisco area practice we've used almost every incision and placed implants in every plane. It depends on the patient.
It appears you're addressing two different issues. One is where your implant sits (under the muscle, above the muscle, "dual plane" (both)) and there are advantages to and negatives for each choice. For most patients under the muscle or partially under the muscle is the most appropriate choice. Typically the "under the muscle" implant is never fully under the muscle except with relatively small implants (typically the inferior edge of the implant is exposed).
The second issue is which incision will be used to place the implant. Again, good and bad things with each choice.
It is important to note that the TUBA approach (through the belly button) in addition to only being able to be used with saline implants, may void the warranty on many implants. This means if your implant ruptures you may not be covered by the extensive warranty that usually protects you.
Make sure you have an in-depth conversation with a board certified plastic surgeon before you make a decision.
I hope this helps!
You have only one chance to have your first breast surgery
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
Breast implants - No key fits every lock
- Periareolar (around the nipple)
- Inframammary (in the crease underneath your breast)
- Transaxillary (through the armpit)
- Periumbilical or TUBA (in the belly button).
I was taught how to do the TUBA from the inventor, and what I learned was that it is not a very good, reliable operation. In the hands of the inventor who has likely done more than anyone else, the reoperation rate for hematoma (bleeding around the implant) and malposition of the implant approached 30 percent.
To a lesser extent, I am not a fan of the periareolar (nipple) incision. It increases the chance of permanent nipple sensation loss, can damage the milk ducts if you decide to breast feed later, and has the most obvious scar of all of them. I try to talk patients out of this approach unless I am doing a breast lift at the same time, which requires that incision anyway.
The armpit incision is a good approach, but you must have the right kind of breast tissue to start with for an optimum result. Discuss this with your surgeon whether you are an appropriate candidate.
The inframammary incision in the crease has shown to have the lowest complication rate, and is appropriate for essentially any breast type. In skilled hands, the incision fades to almost nothing with time.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.