Preferred Placement of Silicone Implants - Sub Pec or on Top of Muscle, After Capsulectomy?

Dear Drs, thanks for your prof.opinion. I decided to have my 40 year old implants removed & replaced w/silicone gel.Present implants are on top of muscle. I was told that I have very little breast tissue. Will addtl breast tissue be lost w/capsulectomy? Would like to remain a "B", I'm petite and thin. Prefer top of muscle for easier healing,is there a chance that the implant would ripple or show? Would I get better results with under muscle or top of muscle placement? Thank you.

Doctor Answers 12

Silicone Gel Breast Implants after Capsulectomy - Above/Below Muscle

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Dear roses7,

As with so many other issues in plastic surgery (and probably everything else) there are no absolute answers to this.  There are some general guideline and then you have to see where you fit in to all of them.  Here's a few thoughts:

1)  Silicone Gel Breast Implants are generally softer and "more natural" and are certainly less likely to ripple than are saline implants.  So to the extent that you have very little skin and subcutaneous tissue of your own, placing implants under the muscle is that much more important for saline than for silicone.

2) Regardless of the type of implant, you Will see and feel the upper edges and sides more if the implant is on top of the muscle than if it is underneath.  As a result most implant are better under the muscle (my opinion, again).

3)  You may have even less tissue left after a capsulectomy (actually, you will) so for the above reasons it makes even that much more sense to place the implants under the muscles.  Just to underscore how important that tissue coverage is for the final result, breast implant revision surgeons are increasingly adding tissue - in the form of acellular dermal matrix (ACD) such as Alloderm or Strattice - to the reconstruction.  These materials, among other things, increase the bulk of tissue covering the implant and make the implant that much less visible.

So - no absolute answers, but you're probably going to be happier with implants under the muscle.

I hope that this helps, and good luck,

Dr. E

With silicone gel implants, placement above or below the muscle is acceptable.

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I disagree with opinions that restrict the placement of the implants (silicone gel) under the muscle.  In the case of saline, I agree.  However, I don't think there is any aesthetic advantage with silicone gel.  I don't have a problem placing them under the muscle, I just don't think that there is an aesthetic advantage unless the patient has almost no breast tissue.

New implants after capsulectomy best under the muscle

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There will be some additional tissue lost with the capsulectomy, and if you are thin then going under the muscle will usually give a better appearance. Your surgeon should work with you on a process for choosong the best size and style of implant.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 59 reviews

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Implant position

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I prefer to keep iimplants in the submuscular pocket( dual plane) because I think that is is better protected in this location.

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Preferred Placement of Silicone Implants - Sub Pec or on Top of Muscle, After Capsulectomy?

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Hello! Thank you for your question! 

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.    Changing position given your statements is a reasonable option to hopefully ameliorate your concerns.

Hope that this helps! Best wishes for a wonderful result!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
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Sub Pec versus Above the Muscle Breast Implant

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Good question and a common situation.  Typically, a small amount of breast tissue is incidentally removed with a capsullectomy, although not enough to make a cup size difference.  If you have very thin breast tissue to start with, this may be important.  Even though silicone rippling is uncommon, it can and does happen in some situations.  Placing silicone implants above the muscle with thin overlying skin is a situation where you may have rippling (although it is not predictable), especially when you are leaning forward.  I agree that your recovery process is easier if you remain above the muscle.  Best wishes!

Brian Howard, MD (retired)
Alpharetta Plastic Surgeon

Breast revision for subglandular implants

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It is always a good idea to place implants under the muscle which provides them increased cushion and allows the pec muscles to continually message the implants. When undergoing breast revision surgery, it is a good idea to place the implants from subglandular to a subpectoral pocket.

Arian Mowlavi, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 108 reviews

Implat exchange

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Usually, minimal breast tissue is removed with a capsulectomy.

I prefer submuscular placement initially. However, if you have subglandular implants that have remained soft, and aesthetically acceptable for 40 years, it is less complex and may be the best plan to put it in the same pocket.  Placing it under the muscle introduces possibility of need for pexy.

It all depends on the breast tissue left after implant and capsule removal

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Under the muscle implant placement generally works better ,but in your case the muscle may not cover the most of the implant and you may get rippling. The rippling will be less with silicone gel implants. The other option that I offer to the patient with very thin breast tissue if fat grafting over the implant in a later date.  

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.8 out of 5 stars 154 reviews

Placing new silicone implants behind the muscle is the right choice

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You are already thin and having a capsulectomy will result in an even thinner tissue layer which may also have irregularities. You would be much better served and have a better result on many accounts by having the implants placed behind the muscle. There will be better support of the implant, lower risk/extent of rippling and lower risk of capsular contracture as just some of the advantages.

Steven Turkeltaub, MD
Scottsdale Plastic Surgeon
4.7 out of 5 stars 33 reviews

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.