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Breast Augmentation Implant Placement

 

 

                                  breast augmentation implant placement - surgical tools

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Once the incision is made - breast implants are inserted into the body in one of four different positions:

 

 

 

 

Subglandular placement or Over the Muscle - breast implants

The implant is placed over the pectoral muscle and under the breast tissue.

 

  • PROS: 

Somewhat shorter recovery and healing time, as the pectoral muscles have not been disturbed.  Because of this fact, usually the pain is much less with over the muscle placement. The placement is much better for patients with mild preoperative sagging and who do not plan to have a breast lift done. If the patient has sufficient tissue to cover the implant, over the muscle placement can be done easily.

Over the muscle placement also gives the implants a much more natural feeling when you use your chest muscles, as there is no distortion of the implant with this placement.

 

  • CONS: 

The implant is closer to the surface and could be more visible under the breast tissue, especially if you do not have a lot of breast tissue to start with.  Rippling is easier to detect in patients with little to no breast tissue. Saline implants and also implants with a textured surface both contribute to this side effect.  Sub-glandular placement may have a higher incidence of capsular constriction. Bottoming out is also a complication of this placement as well, so it is always best to keep your breasts supported as much as possible with a good bra. 

You might need more photos of your breast tissue with a mammogram with over the muscle placement. Best to make sure you go to a technician that is familiar with working with implants. 

If the patient has significant sagging with excess breast tissue - usually a patient will be advised to have a breast lift, as getting implants without a lift is nothing more than enlarging what mother-nature has given you. So if you were saggy to begin this procedure, then usually if you forgo a lift, you end up just a larger version of what you started out with. But if you start with marginal sag or ptosis, then getting over the muscle placement will in fact help lift up the actual breast somewhat.

 

 

 

 

 

 

Below the Muscle - Partial Unders - Sub-Muscular 

The implant is placed below both the pectoral muscle and overlying breast tissue.

Other names for Sub-Muscular Placement:

  • Unders

  • Partial Unders

  • Partial Sub-Muscular

Two-thirds of the implant is covered with the pectoral muscles, and the bottom third of the implant is covered only with breast tissue.  Under the muscle placement involves separating the two muscles - pectoralis major muscle and the pectoralis minor from the chest wall – and inserting the implant in between the two muscles. 

It is very important to ask your plastic surgeon if he or she is recommending partial under the muscle or full/complete under the muscle placement. As these two placements are different from each other.

 

  • PROS:  

Less risk of implant visibility and capsular constriction (however recent studies have proven that both placements have the same risk of this complication more or less). Sub-muscular placement offers less mammography interference; allowing the technician to see the breast tissue much easier.  More appropriate when the patient has a small amount breast tissue.  Implants are less noticeable in terms of rippling and also less palpable. 

Breast profile appears more natural with women with little to no breast tissue – the breast is defined with a more natural slope because of the coverage of the implant by the pectoral muscles. If a woman has weight changes, even due to pregnancy, the muscle supports the implant and therefore the breast and implant are less likely to sag.

 

  • CONS: 

Two to three more days of recovery and somewhat more discomfort.  May not be recommended for highly muscular or athletic builds because of the fact of their over developed pectoral muscles.  Implant distorts when making certain movements – such as swimming, getting out of a pool, opening a jar, etc.  The implant tends to be a bit higher initially on the chest wall with partial unders or partial sub-muscular placement, as this is due to the pectoral muscles. 

Once the muscles relax however, the implants do drop into the pockets that were made.  Because of the placement of the implant only being partially under the muscle, the lower pole is covered with sub-glandular tissue like having over the muscle placement.  This leaves less support for the lower pole of the implant, making it vulnerable to bottoming outAs with any placement of implants, rippling is a fact of life we all come to grips with when we get these devices.  The more tissue you have the better it is going to be with hiding any unforeseen rippling. 

 

 

 

 

 

 

Complete Under the Muscle Placement 

Full sub-muscular placement for breast implants is not as widely used today as Partial under the muscle, but seems to be getting more attention lately. 

 

Complete sub-muscular placement can be achieved by trans-axillary, peri-areolar, and also inframammory fold incisions.  Trans-axillary incision is the only incision that offers no surgical cutting of the actual pectoral or serratus muscle and the fascia.  With the trans-axillary approach the muscles are lifted so that the implant can be placed, which will mean less pain and trauma to the patient. 

With the peri-areolar and the inframammory fold incision – both methods requires some cutting of the muscle in order to place the implant so that it is fully sub-muscular.  At one time, this placement was reserved mainly for women facing breast reconstruction from breast cancer, however some plastic surgeons have seen the benefits of this placement with their patients who have little to no breast tissue.

 

 

  • PROS: 

This method of implant placement usually was reserved at one time solely for reconstructive patients.  But some plastic surgeons are seeing the benefits of this placement with patients with very little breast tissue so that the edges of the implant can be fully camouflaged. Much lower risks of capsular constriction and also bottoming out with this placement. With the implant behind the full muscle, the fascia serves as a support to the device (making like an internal bra).  This is what makes bottoming out less likely to happen. Also, with mammograms, the readings are probably the easiest with this placement, as the implant pushes all the dense breast tissue to the top without any device in its way.  

 

  • CONS: 

The most notable disadvantage of having implants placed completely under the muscle is the pain and the recovery.  The implants will tend to be very high on the chest wall and tight right after surgery. Sub-muscular placement of a breast implant may also contribute to the lack of cleavage with breasts that are widely spaced, especially with the use of textured surface implants

Implant distortion tends to be more when it comes to this placement, as it is behind not only the pectoral muscle but also the serratus muscle. Simple movement might make the implants “dance”, such as opening up a jar or getting out of a swimming pool. Some patients have reported that it takes awhile to get use to the implants in this position with swimming, but as everything in breast augmentation, patience is a virtue and eventually you will not notice every single movement.  

 

Photos showing implants behind the muscle (partial sub-muscular) - and distortion with flexing the pectoralis muscles.

                Under the Muscle breast implant placement without flexing the pectoralis muscles         Under the Muscle breast implant placement with flexing the pectoralis muscles

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                   Without Flexing the Pectoralis                     Flexing the Pectoralis Muscles

 

 

 

 

 

 

subfasia breast implant placement

   Copyright 2008 Nucleus Medical Art, Inc. - Used with permission

 

Subfascia placement is a newer technique that combines many benefits of the two most common placements, sub-glandular and also sub-muscular. This placement is intended as a compromise for women who want sub-glandular placement but also want the benefits of sub-muscular.

The subfascia placement approach is done with elevating the soft tissue connection on top of the pectoralis muscle so that the implant sits under the breast and under the fascia – but over the muscle. The chest muscles are not disturbed with this procedure and the fibrous fascia tissue is dissected away from the front wall of the pectoralis muscles and the implant placed beneath this fascia layer. Subfasia placement takes longer surgically than sub-glandular placement, however substantially less time than the placement of sub-muscular. 

There is nothing in plastic surgery literature that supports this technique over the other type of placements. The theory behind sub-fascia placement is that it provides more soft tissue coverage over the implant without violating the muscle, and perhaps decreasing the risk of capsular contracture.

Subfascia placement works very well for small, thin women who have little or no breast tissue to cover their implants.  The fascia layer helps to smooth and contour the implant shell, blending the implant into the chest wall.

 

Benefits of the Subfasia Placement:

  • Mammogram Screening is easier to read

  • Fewer incidents of capsular contracture than sub-glandular placement

  • No distortion of the implant when using pectoralis muscles

  • More implant support than with either sub-muscular or sub-glandular

  • Less chance of complications compared to sub-muscular approach

  • Surgery is shorter in duration

  • Recovery is shorter than with sub-muscular placement

  • Very natural breast contour

  • Strong implant support from the strong fibrous fascia

  • Fascia placement helps conceal the implant with rippling

 

Contraindications of Subfasia Placement

  • Less chance of preventing capsular contracture than sub-muscular placement

  • The fascia can experience support problems leading to asymmetry

  • The layer of fascia over the muscle is very thin - that sometimes it can tear, and the placement literally becomes sub-glandular.

  • The fascia is a thin but tough layer on the surface of the muscle, so it can be used for support of the implant but it isn't thick enough to add "padding".

  • Some plastic surgeons question the benefits vs. the extra time it takes to do this procedure (Developing a plane between your fascia and muscle may be difficult).

  • More pain associated with this placement vs. sub-glandular placement

 

 

 

 

 

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