Breast implants - what are my options for implant placement?

There are already a number of insightful answers to this important question. It has been stated that every patient is different and one technique is not always the right one for every patient. I agree 100%. Only after a comprehensive discussion about your desires and goals and a though exam can your plastic surgeon best discuss your options with you.

Michael C. Edwards, MD, FACS

Once the type of breast implant and the incision are determined, your plastic surgeon will discuss the optimal placement of the implants to create the best breast form. Classically these options have been either completely behind the muscle, called the submuscular breast implant position, or in front of the muscle, behind only the breast tissue. This latter placement is called the subglandular breast implant position. A third option, and the one that I often use in my plastic surgery procedures, is the dual plane breast implant position and combines many of the best features of the submuscular and subglandular breast implant positions.
The submuscular position for breast implants requires elevation of the pectoralis muscle, as well as some of the serratus muscle in order to have total muscle coverage of the breast implant. This placement has been thought to be the decreased risk of capsular contracture, or problematic scar tissue forming around the breast implant. Additionally the extra muscle coverage adds a layer of natural tissue over the breast implant in order to mask the ability to feel the implant. Unfortunately, women who have some substantial amount of breast tissue, and especially women who have some ptosis, or drooping of the breast tissue, can have difficulties with the placement of the breast implant completely behind the muscle. This is because the natural breast tissue can droop over the muscle and implant, causing a “double bubble”. The double bubble occurs when there is fullness on the chest wall from where the breast implant is being held up high by the muscle layers, while the breast droops down and creates a second, un-natural appearing fullness in a lower position, below the breast implant. This is a tell-tale sign of breast augmentation and a situation that your plastic surgeon should do everything he can to avoid.
The subglandular position for breast implants requires the breast implant to be placed over the muscle, and only behind the breast tissue. This can have a great effect on filling out the lower breast mound by adding volume to the area of the breast behind the nipple. Unfortunately, breast implants placed in this position have a slightly higher incidence of capsular contracture, and are more easily felt and seen without the muscle covering the breast implant in the upper portion of the breast. While the subglandular breast implant position may be a good option in some women who have minimal ptosis and a deflated appearing breast, the difficulties with this breast implant placement often preclude its use.
Here in Santa Barbara, I have found that the dual plane breast implant position, in many cases, combines the best of the submuscular breast implant position with the subglandular breast implant position. The muscle is released from its lowest origin in the inferior and lower medial portions of the breast area. The muscle is elevated in the superior aspect of the breast implant pocket, but the implant is allowed to rest behind the breast tissue in the lower aspect of the pocket where the muscle has been released. This allows the muscle to cover the upper breast implant and hide it from being easily seen and felt. At the same time, the dual plane breast implant position allows the implant to fill out the breast in the lower region, behind the nipple, to create a great teardrop shape and a natural breast appearance. Additionally, the muscle is able to massage the implant in the superior portion of the pocket, and thereby help reduce the problematic scar contractures that I want to avoid.

While the issue of ‘over’ or ‘under’ the pectoralis major muscle receives a great deal of attention, even more important than implant position relative to this muscle is implant position vertically and horizontally on the chest wall.  In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness.

In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that an implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear ‘bottomed out’, with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast – another situation with a distinctly unnatural appearance.

The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Breast implant pockets that extend too fat laterally will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart.  If the pockets do not extend far enough laterally, however, the result is an augmentation with an abnormal ‘side by side’ appearance. As it is the lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an ‘hourglass figure’, careful attention must be paid to ensure that lateral breast projection is adequate and appropriate.

Another consideration is that the implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient who is 5’2” will be inadequate for a large-framed patient who is 5’10”. Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast enhancement.

Implants can be placed either above or below the muscles of the chest.  There are several choices for the site of the incision as well:

-In the crease below the breast

-In the armpit

-In the belly button

-Around the edge of the areola

The choice of whether the implants should be above or below the muscle depends on factors relative to each individual patient.  Where the incision will go is discussed by the patient and the surgeon.  The belly button approach (T.U.B.A. - transumbilical breast augmentation) can only be used when saline implants have been selected.  As the belly button is the only scar you are born with there are no new scars so the result is basically free of any visible scar.

This is something that is discussed at length during a consultation that often lasts between 30 minutes to an hour in my office. It really depends on the patient's anatomy and their preference.

There are essentially 4 routes currently used for breast implant placement. There is

1. Periareolar (around the nipple)
2. Inframammary (in the crease underneath your breast)
3. Transaxillary (through the armpit)
4. Periumbilical or TUBA (in the belly button).

In my opinion, only three of the above are valid accesss sites for implantation, with the TUBA, or belly button site, being fraught with a very high complcation and reoperative rate.

I was taught how to do the TUBA from the inventor, and what I learned was that it is not a very good, reliable operation. In the hands of the inventor who has likely done more than anyone else, the reoperation rate for hematoma (bleeding around the implant) and malposition of the implant approached 30 percent.

To a lesser extent, I am not a fan of the periareolar (nipple) incision. It increases the chance of permanent nipple sensation loss, can damage the milk ducts if you decide to breast feed later, and has the most obvious scar of all of them. I try to talk patients out of this approach unless I am doing a breast lift at the same time, which requires that incision anyway.

The armpit incision is a good approach, but you must have the right kind of breast tissue to start with for an optimum result. Discuss this with your surgeon whether you are an appropriate candidate.

The inframammary incision in the crease has shown to have the lowest complication rate, and is appropriate for essentially any breast type. In skilled hands, the incision fades to almost nothing with time.

There are 3 traditional approaches for breast augmentation:

1. Under arm (transaxillary)
2. At the junction of the pigmented skin of the areola and breast skin (periareolar)
3. Under the breast at the fold (inframammary)

Implant placement through an incision in the belly button has been described, but I am not a fan of this approach. Placements of the implants above or below the muscle can be done through any of the approaches mentioned.

Each incision has its advantages and disadvantages, as well as the ideal breast for which it was designed.

• Transaxillary, under arm, approach is good for small breasted women with small areola and no significant breast fold.

• Periareolar, junction of the pigmented skin of the areola and nonpigmented skin of the breast, approach is the most versatile approach, as the incisions heal very well and are hidden by the color change of the skin. This incision is also part of every breast lift technique if a lift is needed at the time of the augmentation.

• Inframammary, breast fold, approach is ideal for women with enough breast tissue to hide the breast fold when standing. In this situation the incision will not be visible to you when standing.

Your surgeon will also have a preference and will advise you at the time of your consultation. Look at post operative photos and become comfortable with your decision.

I am a very strong proponent of placing implants ABOVE the muscle. Because part of the pectoralis muscle is usually cut in order to fit the implants, this causes some of the muscle to atrophy (die).

Under the muscle has many other disadvantages such as severe post-operative pain, but there are no advantages that I can discern after using both positions for over 30 years. In addition, placing the implants over the muscle does not require general anesthesia.

Breast implants can be placed in several different locations ranging from submuscular, partially subpectoral, subfascial or subglandular.

Total submuscular placement implies complete muscle coverage. This is not feasible with cosmetic breast augmentation since the pectoralis (chest) muscle inserts on the ribs above the bottom fold of the breast. Thus, in order to get the breast implant low enough on the breast to reach the inframammary fold, the muscle attachments to the low ribs must be released; which in turn creates a partial subpectoral pocket.

Additionally, the lateral aspect of the breast implant is usually not covered by muscle as well since the muscle comes across the breast at an angle from the shoulder to the middle of the chest in a fan shape.

• The only time an implant is truly completely submuscular is in cases of breast reconstruction for mastectomy when the lateral chest wall muscles are elevated to cover the implant.

• This is not used in cosmetic breast augmentation because this added dissection leads to too much discomfort afterwards.

The partial subpectoral or partial submuscular pocket is also known as the "dual plane." As the name suggests, the implant is covered at the bottom and side only by the breast tissue and superiorly and medially by the pectoralis major muscle.

• This is the most common breast implant placement pocket, especially for saline implants.
• It is used widely for patients that do not have a lot of coverage at the top of their chest to help hide the implant.
• The dual plane position makes the recovery more painful than a more superficial plane. Additionally, some patients can be unhappy with distortion of the breast and nipple with contraction of the muscle.

A recent study presented by Scott Spear, M.D. at the American Society for Aesthetic Plastic Surgery Meeting in San Diego May 5, 2008 showed that 10% of the patients with implants in the partially subpectoral location had significant and problematic distortion of the breast that required intervention. This is especially prevalent in patients that are muscular and physically fit who like to work out and lift weights, including their chest muscles.

The FDA reports that mammogram may be more accurate in this position as compared with the subglandular or subfascial pockets. However, many radiologists disagree with this blanket statement and feel that mammography is equally impaired by breast implants in any plane. These radiologists suggest that the presence of capsular contracture (thickening of the tissue around the implant, making it firm) actually causes the worst impairment of mammography regardless of the position of the implant.

The subglandular pocket is directly under the breast gland.

• This was a very common pocket used for silicone implants since they were first introduced in the 1960s.
• The pocket has advantages of a less painful operation and no distortion of the breast with contraction of the muscle.
• In thin patients, there is a risk of implant wrinkling and rippling.

The subfascial pocket is a newly described implant position that has some advantages of each of the above mentioned pockets. The subfascial pocket is deep to the breast tissue and under the thick coating of the chest muscle (pectoralis), but above the muscle mass itself.

• This thick coating helps hide the edges of the implant, especially at the top and middle of the chest where the skin gets thin.
• This may cut down on visible wrinkling and rippling.
• There may be a slightly higher rate of capsular contracture in the subglandular and subfascial planes in older breast literature, but recent studies seem to suggest that the rate is equivalent.

Patients have many potential options in the selection of the proper breast implant for their own optimal result.

Of course, working with an excellent and experienced plastic surgeon is essential and your surgeon should carefully explore what kind of size increase and upper pole profile look you feel would be best for you. Following this, a careful dimensional measurement of your chest wall should put you and your surgeon into the area of the implant catalogue where the diameter of the implants match your own diameter well.

The volume of the implant just follows along with the diameter that best suits you, so don't get hung up on the volume because the diameter is actually more important in getting you the right implant. The profile of the implant determines the "look" in terms of cleavage and upper pole fullness. The "moderate" profiles look the most natural while the "moderate plus" and "high" profile implants are designed to create greater cleavage beyond what would be natural.

Silicone gel implants are selected by patients who place a high priority on the "feel" since they feel more like natural tissue. Saline implants are selected by patients who believe they are "safer" and feel more comfortable with them and are willing to be able to detect the edge of the implant laterally and not have that bother them.

Round shaped implants, both saline and gel, work better for augmentation because the tear drop shaped implants don't always heal symmetrically and they can therefore look very different from each other and require more surgery for correction.