Lateral Displacement and Flex Distortion of Implants? (photo)

Question

Hello! I had a BA 8 months ago with 300 ccs silicone implants under the muscle. Do I have lateral displacement? At first I loved it, now I have NO inner cleavage and any fullness I have is near my armpits. When I lie down on my back my chest goes flat and my implants fall into my armpits. Also, when I flex my pecs, I have distortion of my breasts- they ride up from the bottom. What would fix these issues? If I get a revision- what size implant would you recommend? I am 5'5", 115 pounds, 3 children.

Johnny Franco, MD, FACS · Answer

Breast augmentation is most commonly placed under the muscle for multiple reasons, however occasionally patients do benefit from the implant placed over the muscle.

Let’s start with reasons why the breast implants are placed under the muscle.  The first, is that the risk of capsular contracture has been found to decreased when the implant is placed below the muscle.  It is believed that the constant motion of the muscle keeps the implant moving just subtly and thus keeping it soft.  The second reason is that the muscle provides additional coverage over the breast implant, giving it a softer feel and decreases the appearance of rippling from the breast implant.

The new gummy bear (highly cohesive) breast implants have helped with many of the issues that placing the implants under the muscle have treated.  The gummy bear implants have decreased the rippling that can be seen when compared to saline breast implants.  Also, the advent of the Keller funnel and antibiotic solutions used during a breast augmentation have decreased the risk of capsular contracture.

The benefit of placing the breast implant in the subglandular (above the muscle) is that it prevents something called animation deformity.  This is when the breast implant moves as the muscle is flexed.  Remember a little movement is great to prevent capsular contracture, however if the implant moves a significant amount it can be disturbing to the patient.  If the breast implant is over the muscle, then there is very little movement of the implant when the muscle is flexed.

I typically will place the gummy bear breast implant over the muscle if someone has animation deformity.  This will reduce the movement of the implant when the patient is moving and flexing.  Bodybuilders and other patients that are at risk of animation deformity I may also place the implant over the muscle during their breast augmentation to avoid this issue.

There are pros and cons to both a subglandular and submuscular placement of the breast implant.  It is important to discuss both of these options during your consultation with your Board-Certified Plastic Surgeon.  The highly cohesive breast implants have given patients and plastic surgeons more flexibility in the placement of the breast implant.

Earl Stephenson, Jr., MD, DDS, MBA · Answer

There are several points that need to be addressed.  Before surgery photos may show that you have wide set breasts which the implants will be wide set (ie . no cleavage).  The muscle movement comes with placing the implants beneath the muscle.  Placing the implants above the muscle does solve this problem but you must have enough thickness of tissue to hide the edges of the implant.

	Dr. ES

Kenneth Hughes, MD · Answer

The pocket can be revised with capsulorrhaphy sutures to block lateral migration and create the illusion of more medial fullness.

Vincent N. Zubowicz, MD · Answer

As the pectoralis muscle is engaged after sub muscular breast augmentation the vector of force on the implant can push it laterally. Over time this can become a chronic problem. Moving the implants to a sub glandular position where fixed the problem

Richard H. Tholen, MD, FACS · Answer

You are tall and slim, with very little of your own breast tissue. Swelling after surgery, as well as more medial placement of your (conservatively-sized) implants, initially gave you more fullness and cleavage. Over time, swelling diminished, tissues compressed and stretched somewhat, and your muscle (pectoralis major) contraction pushed your implants laterally, as well as giving you flexion distortion of the lower pole of your breasts.

	All submuscular implants, particularly in very thin women, can exhibit some degree of activation distortion. To minimize this, careful release of the inferomedial pectoralis fibers as they attach to the sternum and parasternal tissues is performed during surgery or revision. Over-release can leave the overlying tissues extremely thin, so this is one of those skill, judgement, experience issues that we all have to deal with accordingly in each specific patient.

	I agree with Dr. Repta's analysis and ideally would stay submuscular, but with larger (and wider) silicone implants to more adequately fill your pockets after additional judicious inferomedial pectoralis fiber release bilaterally. Wider (lower profile) implants may circumvent the need for lateral capsulorrhaphy (tightening the pocket on each side), or that may be still needed.

	While subfascial implants (or submammary, for that matter) can solve the activation distortion problem, it potentially increases edge or ripple visibility (less with silicone implants, much more with saline in thin patients), not to mention increasing risk of capsular contracture. BIgger problems, so I too would stay submuscular, even if there is still some activation distortion present. Flexion distortion is most evident to the patient when nude, but much less so to others, even when swimming or exercising.

	To make even a minimally-visible implant enlargement worthwhile, I would go up 125-150cc (about another half cup size) to 450cc implants (moderate profile). For more enlargement, add accordingly, but I would probably stay below 550cc or so. Discussion and physical examination trump any on-line advice, however! Best wishes and Happy Holidays! Dr. Tholen

Steven Wallach, MD · Answer

First, I can not tell witha bra on whether you have lateral displacement. You did not have cleavage to begin with and unfortunately, your anatomy dictates some limitations. If you have issues with lateralization , you may require a pocket revision.

Darryl J. Blinski, MD · Answer

It appears as if you had axillary incision as the site of insertion??? If true than the muscle dissection was not completed medially in my opinion. Also increase in size to 400/450 UHP is my recommendation.

Kamran Khoobehi, MD · Answer

You have minimal breast tissue and also very strong upper body. The placement of the silicone implant under the pectoralis has the down side of implant lateral displacement. This is more common in patients that continue upper body workout. The cause of displacement is limited release of the pectorals muscle. I do offer implant pocket revision,fat grafting to enhance the cleavage and release of the pectoralis muscle to let the implant expand the lower pole of the breast.

Remus Repta, MD · Answer

Hello,

	Thank you for the question and the photos.  Breast animation (breast movement with muscle contraction) is always present to some extent with implant placement under the muscle.  Breast animation is increased when the pocket is over dissected.  During your revision the side of the pocket can be repaired (closed), the muscle over the sternum can be properly opened, and an implant suited to your goal can be replaced (wider implant).  Often all of these are performed.  You could also have the implant replaced in a subfascial position as this would also correct the animation aspect of your breast issue.  You are fairly thin so I would go with the first option of modifying your breast augmentation but keeping the implants in the sub-muscular position.

	All the best,

	Dr Remus Repta

Hilton Becker, MD · Answer

Lateral displacement and flex distortion can be seen with sub-muscular placement of implants

	I would recommend sub-fascial placement to correct your problem

Lateral Displacement and Flex Distortion of Implants? (photo)

Answers (11)

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