Are implants under the muscle better and do they last longer?

Question

friends i have spoken to have told me that implants under the muscle are better especially if you are planning to have children in a few years. my surgeon said that he does not want to put them under my muscle because there is no need as i have good breast tissue ?

Jerome Edelstein, MD · Answer

Hello,As others have said, many women will prefer submuscular if they have thin tissue/skin as this allows the muscle to camouflage the upper pole for a natural look. when therre is sufficient breast tissue/fat, submammary can appear natural as well. If you are a candidate for either, choose what you want. Be sure to seek a board certified Plastic Surgeon who specializes in this area.All the best

Donovan Rosas, MD · Answer

When
undergoing breast augmentation there are a number of choices which need to be
made: saline or silicone? Volume: Larger or smaller? Incision? However, one of
the most commonly debated choices is that of implants placement: subglandular/
submammary vs. subpectoral/ submuscular? While many surgeons recommend
submuscular placement there are distinct differences to each approach.Subglandular Augmentation:Subglandular augmentation means place
of the implant underneath the breast tissue but above the pectoralis muscle.
Subglandular placement spares the pectoralis muscle which leads to reduced post
operative pain/discomfort and no impact on muscle function post augmentation.
Recovery is also faster when compared to subpectoral augmentation.Subglandular augmentation can impact
mammographic evaluation of the breast. However, as dedicated breast radiography
has become more prevalent this has become less of an issue. Fellowship trained
radiologists have become familiar with evaluating breasts post augmentation. It
is also important to note that implant position does not interfere with
visualization of breast tissue via contrast enhanced MRI (the most sensitive
and specific study available for breast cancer detection).Studies suggest there is an increased
risk of capsular contracture when implants are placed in a subglandular space.Aesthetically, implants placed superficial to the pectoralis major create a rounded,
convex appearing breast profile. This effect is camouflaged, at least initially
in larger breasted patients. However, as a woman ages fat atrophies and breast
tissue descends. The result is a more noticeable implant specifically in the
upper pole. Similarly, patients who have thin coverage superiorly are more
likely to be able to perceive the implants and at higher risk of visible
rippling.Subpectoral Augmentation:Subpectoral augmentation is
technically a bit of a misnomer. Traditionally, subpectoral augmentation
involves the release of the pecotralis major muscle from its lower attachments.
This allows the muscle to “window-shade.” The upper hemisphere of the implant
sits underneath the muscle (dual plane). This release contributes much of the
discomfort encountered postoperatively by patients.Subpectoral implants have a lower rate
of capsular contracture.Aesthetically, in contrast to
submammary implants (which are prominent in the upper pole- especially in
thinner patients), the pectoralis muscle both conceals the underlying implant
and flattens the upper pole. This flattening effect creates a natural sloping
as one proceeds from the upper portion of the implant to the lower portion.

Each approach has
both costs and benefits. Patients are unique and so too is each operative plan.
A potential augmentation candidate may be better suited for one approach or the
other.  As always, your board certified
plastic surgeon can help guide you in your decision making process.

Lewis Albert Andres, MD · Answer

Hello! Thank you for your question!  Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts.  Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years.  In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance.  Your breast width is the most important measurement.  Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant.  This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape.  Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width.  Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later. Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle).  Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each.  In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome.  A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles.  Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions.  As you see, there are a few factors to decide upon for incision, placement, and implant type/size.    Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits.  Hope that this helps! Best wishes for a wonderful result!

Nana N. Mizuguchi, MD, FACS · Answer

As long as you are a candidate for on top of the muscle, you will do fine.  Most patients who seek breast augmentation do not have adequate breast tissue so implants need to be placed under the muscle.  I perform almost exclusively under the muscle breast augmentation.  That is simply my bias and experience.Best Wishes,Nana Mizuguchi, MD

Jaime S. Schwartz, MD, FACS · Answer

I appreciate
your question.

The best way
to determine implant size is based on chest wall measurements that fit your
body.  Once we determine that we can choose the profile based on what you
want or need to achieve.

Implants
under the muscle, there is less risk of capsular contracture.  Anatomic
implants tend to give a more natural shape with more nipple projection.

The best way
to assess and give true advice would be an in-person exam.  Please see a
board-certified plastic surgeon that specializes in aesthetic and restorative
breast surgery.

Best of luck!

Dr. Schwartz

David A. Lickstein, MD · Answer

Most implants are placed under the muscle for a few reasons - they are less palpable, and less likely to show rippling with more soft tissue coverage.  Additionally, this is a separate plane when mammograms are done.  Implants above the muscle require sufficient soft tissue coverage to avoid these issues - and far less women are good candidates.

Tom J. Pousti, MD · Answer

Thank you for the question.There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”. I will try to outline some of the differences here; you may find the attached link helpful as well.I think it is in the best interests of most patients seeking breast augmentation surgery to have implants placed in the “dual plane” or sub muscular position. This positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability of the implants (which may increase with time, weight loss, and/or post-pregnancy changes).The submuscular positioning also tends to interfere with mammography less so than breast implants in the sub glandular position. The incidence of breast implant encapsulation (capsular contraction) is also decreased with implants placed in the sub muscular position.On the other hand, sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants seen with flexion of the pectoralis major muscle) they can be seen with breast implants placed in these sub muscular position. Best wishes.

Hiroshi Nishikawa, MD, FRCS - Account Suspended · Answer

The choice of where to put the implant, either above or under the muscle, is usually a clinical and technical matter.  In my practice this depends on how much overlying breast tissue is present over the muscle.  If there is very little breast tissue then the implant should be placed in a submuscular pocket.   This is to ensure that the implant is well covered by healthy tissue and is well protected.  Also, in very thin ladies with little breast tissue, putting it under the muscle will help to ensure that the implant itself is not directly palpable.However, there is no evidence that they last longer when placed underneath the muscle or that there is a decreased rate of capsule formation.  In general, placing the implants under the muscle causes more post-operative discomfort and a slightly longer recovery time.  However, the cosmetic results should be as good as implants placed directly under the breast (subglandular implants).

Are implants under the muscle better and do they last longer?

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