Inferior Support after Breast Implant Placement: Maintenance of lower pole tissue support or addition of support.
No matter what technique is used, lower pole support is identical. The lower pole of the breast is defined by the inframmary fold (IMF) and this is a couple centimeters below the insertion of the pectoralis muscle and the origin of the abdominal fascia. If the implants are placed completely under the muscle they will be too high!
Placement of implants in a normal breast, typically has enough support to withstand the weight of the breast implant, but the larger the implant, the heavier the weight and the more risk of bottoming out. Thin women who workout, could benefit from a smaller more athletic implant for a more natural look, but placement under the muscle will only help with the upper breast shape. The extreme I would allude to and you bring up a great point is in the breast that has lost all support, such is in a mastectomy patient: who benefits from lower pole support with an acellular dermal matrix to help with that soft tissue support. This is not necessary or cost effective in primary breast augmentation.
Other options you could consider to eliminate animation deformities with pectoralis movement may be a subfascial anatomic cohesive gel textured implant, that may give you the shape and size you want with the support of the texture. These are firmer and require a larger scar.
Great question, and you have options!
What supports a #BreastImplant?
That's a terrific and educated question. There are basically two parts to your question. The first is what supports an implant. The second is whether or not you should have your implants beneath the muscle.
A good consultation should answer these questions in great detail as they are two of the most important issues to decide upon.
In short, Neither subfascial, submuscular, subglandular nor dual plane augmentations use different tissues to hold the implant from underneath. In each of them, the tissue you would expect to hold the implant is cut. Meaning the muscle is cut at the bottom in submuscular augmentation, the muscle is cut in dual plane, there is nothing in specific to support the implant in subglandular position and the fascia, though fairly thick at the top of the muscle in some is tissue-paper thin at the bottom of the muscle. Certainly not strong enough to be solely responsible for holding an implant in position.
What holds the implants in position seems to be ligament type structures at the base of the breast. These are preserved in most cases no matter how the augmentation is performed. When they are not preserved, the implants bottom out regardless of where they started. In other words, there is no reason to think that one position provides dramatically more support for an implant in most cases.
Regarding your second question, implants under the muscle in very active or strong women can run the risk of moving excessively in time. The easy solution is to stop isolating your pec muscles with your exercises. You are unlikely to dramatically benefit from better pec definition after an augmentation anyhow. The alternative, as you described, is above the muscle or subfascial. The risk there is being able to see or feel the implants in time as the swelling subsides. This is less likely with silicone than saline implants but more likely in women without much breast tissue over the implants.
As you can tell, there is a lot to discuss and this is just the tip of the iceburg. If you feel like your consultation didn't adequately answer these questions, it may be worth another consultation somewhere else. Keep looking until you find an office where you feel comfortable.
What supports the breast from below with submuscular or dual-plane placement?
There is in fact much very little support offered by the lower portion of the muscle where it becomes thinned and often absent, With the dual plane technique there is no muscular support inferiorly as it has been divided at this level.
The muscle often causes discomfort and animation deformity on contraction ,especially in muscular or athletic patients.
It is for these reasons that I place smooth round implants in the sub -fascial position.
I am seeing more and more patients wishing to convert their sub-muscular implants to the sub-fascial position. These patients are generally very happy with the new position.
Inframammary fold attachments to the dermis can support the implant in the short term. Once the tissues have healed after implant placement, a capsule that forms around the implant provides further support. That is why excercise is not encouraged for 4-6 weeks. There are many benefits to under the muscle placement and is the reason why most implants are placed in this or a dual plane technique.
You are correct, the only way to support the inferior pole in breast augmentation is Subfascial Placement.
Your question is very insightful. the way most surgeons perform breast augmentation is what the public calls "under the muscle." It is really a dual-plane augmentation. A small part of the top of the implant is covered by muscle and the majority of the breast is sub glandular. This leads to the widely separated low breasts with a fat shelf like superior pole. This is exactly why I developed a technique called the Cold-Subfascial Breast AugmentationR. It is a subfascial placement that is modified to preserve the fascia in its entirety and provide full fascial coverage and support. The results are a natural non-augmented appearance, a full superior pole and lasting support without the dreaded muscular animation or "muscle jumping" so common in sub muscular implants. I hope this helps!
All the best,
Rian A. Maercks M.D.
Great questions, so if the patient is really muscular I will typically put the implant above the muscle more for the distortion than the worry about bottoming out, I typically will use a shaped textured implant because it will be less obvious
Lift weights and train uninhibited with submuscular breast implants
I agree with Dr. Grzeskiewicz in general. As an added point, many bodybuilders, weight lifters, trainers, yoga instructors, aerobics instructors, ultra runners, and athletes of all types cross our door, because this is what we do day in and day out is breast augmentation for healthy women. Submuscular placement is most often the favored choice and virtually less than .5% of bottoming out will occur because we honor the width of the breast guiding the diameter and keep breast implant size small as this translates to weight, carefully create the pocket without over operating which then minimizes the size and helps speeds recovery as well as allowing the implant to maintain its position. After 4000 implants (average 30-40 per month) we favor a textured implant of highly cohesive gel or gummy bear type. These have the best feel, shape, textured and after 10 years of gummy bear experience, feel these will allow for the best long term result.
Support of the breast implant below is an important issue
Your question brings up many good points for discussion. The main issue isn't necessarily whether there is something pushing up on the implant from below to keep it from lowering, or "bottoming out," rather it is really what keeps the implant in place, period. This can be tissue support from below, like muscle or even a prosthetic sling, like Seri or Strattice, or it can be the implant itself, when it is textured. You are right to express concern over downward displacement of your implants with vigorous use of the pectoralis muscles, because it is well described how frequent downward forces from the muscles can displace implants downward. For this reason I tell all of my patients to limit the amount of direct pectoralis strengthening exercises that they do. Sometimes we have to set our priorities, and if it is beautiful breasts we may have to trade off some specific exercises, in exchange for minimizing the risk of implant displacement. If they can't for some reason, such as being a competitive athlete or body builder, then I suggest textured implants, round or shaped, above the muscle. This then leads to the discussion of the anatomy of breast augmentation. Most surgeons will tell you that some form of submuscular placement is usually better, and in general, I agree. In actuality however, the bottoms of most women's breasts rest below the bottoms of the pectoralis muscles, thus, attempting place the implants above the lower edge of the pectoralis will result in them being placed way too high in most cases. This is also true for subfascial placement, as the fascia that is usually being discussed as not being separated from the breast tissues is the pectoralis fascia, which, like the muscle it invests, would be ABOVE the implant, not below it. Some surgeons may elevate fascia or muscle from the serratus anterior, or even the upper abdominal muscles, to put the implants beneath, but I think this is way more invasive than need be, and it often gives a distorted appearance to the breasts. Personally, I almost always use some variation of a dual plane placement, always submuscular, and almost never subfascial, and I never like to say never in surgery, but I "never" have problems with bottoming out. This is because the inframammary fold tissues are actually more like a wide band, or strip, of strong tissues that secure the bottom of the breast to the underlying muscle wall, as opposed to a thin line and if one is careful when working with this tissue, its integrity and strength can be maintained, and thus the support for the lower breast will be retained. In addition to this, I almost always use a reinforcing suture, Dr. Charles Randquist calls his the "Lucky 8" suture, which further secures the tissues of the inframammary fold to the underlying rib lining, thereby maintaining the position of both the fold and the inframammary incision. The idea is to force the tissues between the nipple and the fold to stretch and expand with the implant, rather that to allow the implant to creep behind and then below the inframammary fold tissues, thus leading to bottoming out. This approach works even when using shaped implants where I may be lowering the inframammary fold position 2, 3, or even 4 cm below its original position. And again, no bottoming out. The texturing of the implant provides enough friction to maintain implant position, a carefully dissected pocket ensures that the implant is placed where you want it to be, and reinforcing sutures give you that added peace of mind and security that things won't head south, even with exercise down the line. Thus, the issue isn't one of needing muscular support from below to stabilize the implants - in fact, I think muscle support below blunts the normal, free form arc of the breast and can result in a breast mound that is too high on the chest. Rather, the issue is carefully planning and executing the right techniques to control your implant position long term and create a natural appearing breast. No breast implant will withstand huge amounts of force from above due to vigorous pectoralis exercise, so if this is truly in the cards for you, you may want to consider subglandular or subfascial placement of your implants to prevent putting them under the muscles where they can be subjected to those downward forces. Good luck.
Sub muscular vs Sub Glandular placement
Submuscular placement may be more uncomfortable the first few days following surgery. The possible benefits of submuscular placement are that it may result in less palpable implants, less capsular contracture, and it will make it easier to image the breast with mammography. The appearance may be more “natural” for patients who are very thin. Subglandular placement may make your surgery andrecovery shorter and you may have less discomfort. This placement may provide a slight “lift”. Subglandular placement may result in more palpable implants, more capsular contracture and more difficult imaging of the breast with mammography. This placement is often recommended for those patients with sagging, but do not want a breast lift (mastopexy) and for tubular breast deformity
Support for the breast below
One of the things that can happen post op from a breast aug is bottoming out.this is not uncommon in women who have had several children and their ligaments below their breats are weak andtheir tissues are thin and then the implant is placed belwo the muscle.To help in these case to give them support I will place several sutures of non absorabable suture material to provide support to these areas and this seems to work well.