Breast Augmentation Frequently Asked Questions

Breast Implant Placement Questions

Which is the best breast implant placement?

The issue of breast implant placement boils down to two principal approaches: either placing the breast implant under the pectoralis major muscle, which underlies the breast, or placing it over the muscle. A third option places the breast implant under not only the pectoralis major but other associated muscles as well. The third approach is more commonly used with breast reconstruction. There is no clear consensus among plastic surgeons. Each of the two principal approaches has its supporters and proponents. Each person's own physical characteristics may make the choice for one woman or her surgeon entirely different than the choice for another. Let's take a look at the three options.

Subglandular or Over the Muscle

 

The breast implant is placed above the pectoral muscle and below the mammary gland. The placement is also sometimes called retroglandular or submammary.

 

Pros:

• Less complicated surgery
• Less postoperative pain
• Quicker recovery
• Women with a small amount of ptosis (sag) may opt for subglandular placement if trying to get some lift without a partial or full mastopexy (breast lift)
• In bodybuilding women, subglandular placement avoids the odd appearance which can result during flexing of muscles, when implants have been placed under the muscle, although most other people would never notice

Cons:

• The implant outline is more visible
• More likely to feel the implant through the skin
• Capsular contracture is slightly more likely
• Mammography can be obscured and, at best, is more difficult
• The risk of visible rippling of the implant is heightened because very little separates the implant from view
• Little support for weight of implant creates risk of needing a lift later

Submuscular, Subpectoral, or Under the Muscle

Submuscular or subpectoral means the breast implant is placed below the pectoralis major muscle. The breast implant is only partially submuscular because the pectoralis major muscle does not extend far enough to cover the entire breast implant, thus the lower portion of the breast implant is not covered by muscle. This placement is sometimes called retropectoral.

For breast augmentation, Dr. Pittman–Waller prefers the submuscular placement.

Pros:

• Lower risk of capsular contracture
• Lower risk of visible rippling although palpable or visible rippling is possible at the bottom of the implant which is covered only by skin or breast tissue
• Outline of the implant is less visible
• Less likely to be able to feel the implants through the skin
• Smoother contour from clavicle to nipple, without a demarcation line
• Muscle massages the implants, keeping them soft
• Better imaging on mammograms
• May delay future sagging

Cons:

• May appear higher in the chest in women with sag
• The breast may bulge at the bottom, known as double bubble
• Implants take longer to drop after surgery
• Muscles may be visible over the implant when contracted during exercise and may press the implants laterally, giving a temporarily unusual appearance hardly noticed by others
• Rippling still possible on bottom of implant
• Lack of support for the weight of the implant at the bottom may create the need for a lift later
• Muscle force may push implant up or down too far, requiring surgery to correct

Fully Submuscular or Fully Under the Muscle

The breast implant is placed not only below the pectoralis major muscle, but also below the associated muscles at the lower part of the breast implant, the rectus abdominus fascia of the upper abdomen and the serratus muscles, so that the breast implant is completely covered by muscle tissue. More often used with breast reconstruction than with breast augmentation.

Pros:

• Lower risk of capsular contracture
• Lower risk of visible or palpable rippling
• Outline of the implant is less visible
• Less likely to be able to feel the implants through the skin
• Smoother contour from clavicle to nipple, without a demarcation line
• Muscle massages the implants, keeping them soft
• Better imaging on mammograms

Cons:

• Less natural appearance in women with sag
• The breast may bulge at the bottom, known as double bubble
• Implants take longer to drop after surgery (often longer than partially submuscular placement)
• Flexing of muscles during exercise can contract implant into an unnatural appearance

What does Dr. Pittman–Waller recommend?

Dr. Pittman–Waller recommends a submuscular or subpectoral placement in most cases. She believes it gives a more natural look and feel to the breast. For most saline breast implants, she uses an endoscopic technique as illustrated above, with the incision made in the armpit, where the scar will be less visible. For silicone breast implants, she recommends a submuscular placement through a periareolar incision, with the incision made around part of the areola where it meets the normal skin tissue. Silicone breast implants are prefilled and cannot be placed endoscopically, from remote locations like the armpit or the navel.

(Illustration from Grabb and Smith's Plastic Surgery, 6th edition, Charles H. Thorne, ed., 2007, p. 577, Philadelphia: Lippincott, Williams & Wilkins)

What is the aesthetic difference between breast implants placed in front of the pectoralis muscle and breast implants placed behind the pectoralis muscle?

Aesthetically, the primary difference is that the muscle covers the upper part of the breast implant, making it less likely that the breast implant can be seen under the skin. The degree to which the placement affects the final result depends, in part, on the change in size, the body of the patient, and the size of the breasts before augmentation.

When is it important to place the breast implants behind the muscle or subpectorally?

When the patient has small breasts, generally an A cup or smaller preoperatively, there is normally not enough breast tissue to cover the breast implants properly and the muscle tissue is needed to keep the breast implants from showing through the skin.

When a patient wants to go to a large size, a full D cup or larger and does not have enough breast tissue and thin skin, then the muscle is needed to cover the breast implant and keep it from showing through the skin.

A further problem of having too little breast tissue is rippling or contour irregularities. A submuscular placement can help prevent rippling over much of the breast implant, the part covered by the muscle.

Can I work out my chest muscles if I have subpectoral breast implants?

Yes, you can continue to work out with submuscular placement, although the contractions of the pectoralis muscles may be more noticeable—at least to you. It is normally hardly noticed by others. When the pectoralis muscle contracts it may also flatten out the breast implants momentarily. This massaging, on the other hand, may keep them softer and more supple.

Do breast implants placed over the muscle drop faster than those placed under?

Yes. Subglandular (over the muscle) breast implants only have the skin and breast tissue to keep them in place. As the skin stretches, the breast implants will drop. Submuscular breast implants also have the pressure from the muscle, so they normally drop more slowly. The difference, of course, will be affected by many factors, such as the size of the breast implants, breast implant textures, and postoperative instructions. If the doctor advises you not to wear an underwire bra, you may drop faster. At times, however, she may ask you to wear an underwire bra so you don't drop too much.

I know I need a lift, but I don't want the scars. Can I get subpectoral breast implants without a lift?

If you need a breast lift and want to have subpectoral breast implants, you may run the risk of developing an unpleasant and unsightly complication known as "double bubble." The natural mass of the drooping breast will hang low while the mass of the breast implant may remain higher, thus giving two bulges of mass, sort of like a double chin for the breasts. If you need a breast lift, it's usually best to have it done.

Should I get smooth or textured breast implants?

The decision is yours, but a textured surface is recommended for contoured breast implants so that the breast implant doesn't rotate. Dr. Pittman–Waller normally uses round breast implants placed subpectorally for which she prefers a smooth surface. The doctor feels they have a more natural feel and motion to them.

Do I have to massage my breast implants?

Massage has its proponents and detractors among plastic surgeons. Many believe that massage keeps the pocket open and helps avoid capsular contracture and many do not. Proponents for massage feel that it will help keep the pocket open so that the breast implant can move around naturally and the muscles can massage the breast implant. Some surgeons believe that manual compression or squeezing of the breast implant keeps the fibrous capsule that forms around the breast implants from contracting and thereby compressing and constricting the breast implant.

Some surgeons believe that massage is only necessary for subglandular breast implants as the pectoralis muscle regularly massages the breast implant through its normal contractions during the day and night.

Capsular contracture, however, occurs with both subglandular and submuscular breast implants, although the rate may be slightly less with submuscular.

Dr. Pittman–Waller normally recommends that her patients begin to massage their breasts beginning two to three weeks after breast augmentation surgery in order to keep the breast implants mobile and supple.

Which placement helps hide rippling?

Rippling is the appearance of ridges or scalloping of the breasts that can be felt and sometimes seen. In cases of severe rippling, it can be clearly seen. Some rippling only appears when a person bends over or moves in a certain way. Sometimes it only happens when lying down. At any rate, it is unattractive and a tell–tale sign of breast implants.

Rippling can be lessened by using optimal fill amounts in saline breast implants. Placing the breast implants under the muscle will lessen the chance for rippling appearing on top, on the outer sides, and in the cleavage of the breasts, although it can still appear in the lower part and underneath, which is not covered by the muscle. In some thin and thin-skinned individuals, however, rippling appears no matter what is done.

Is breast cancer easier to detect with subpectoral rather than subglandular breast implants?

Let's answer another question first. Long–term, large–scale studies have shown that there is no difference in breast cancer rates between women with breast implants and women without breast implants.

With regard to breast cancer detection, it has been found that submuscular breast implant placement allows for greater visualization of the breast when compared with subglandular placement, regardless of breast size and breast implant type and size.

Using the Eklund mammography technique, a mammographic view that displaces breast implants to increase the amount of breast tissue that can be seen, about 85% of the breast tissue of women with submuscular breast implants can be visualized, compared with 64% for women with subglandular placement and 90% or more for women without breast implants. Compared with the standard view, the Eklund technique increases the breast tissue revealed from 56% to 64% for subglandular placement of breast implants and from 75% to 85% for submuscular placement.

With MRI imaging, 100% of the breast tissue can be seen in women with breast implants, although to realize its full diagnostic capabilities, an intravenous contrast medium is necessary. Although MRI has a sensitivity of 90%, its limited specificity is a known disadvantage, as malignant lesions can be mimicked by benign tumors, hormonal stimulation, and inflammatory changes.

Nonetheless, studies have demonstrated that women with breast implants have their cancer detected earlier than women without, when the tumors are smaller and easier to deal with. Furthermore, about 40% of the breast cancers are detected by mammograms in women with breast implants, a rate that closely resembles that of women without breast implants.

Lastly, there appears to be no difference between saline and silicone breast implants in terms of mammography results.

Do breast implants rupture more often with subpectoral than with subglandular breast implants?

First of all, rupture rates are very low for women with their first breast augmentation surgery. The Mentor Core Study on Silicone MemoryGel Breast Implants found a suspected rupture rate using MRI of 0.5% for primary augmentation. Studies of complications among women with breast augmentation in Finland and Denmark showed rupture rates of less than 1% for all types of breast implants.

As a practical matter, then, the rupture rates are so low that the difference between one placement or the other would have little practical effect. Finally, surgeons are divided on whether there is any difference at all.

Is the rate of capsular contracture higher with subglandular than with subpectoral placement?

A number of studies have found that submuscular placement of breast implants reduces the risk of capsular contraction after breast augmentation surgery. The long–term rate of capsular contraction is about 15%. The most recent study also found that rates of capsular contracture are falling as surgical techniques and breast implant devices improve.

Can I go without a bra—particularly if I have subpectoral breast implants?

No. If you go without a bra, you will sag, period. As you age, the skin loses its elasticity and it becomes thin and stretched out by the weight of the breast implant. Therefore, it's best to wear a supportive bra to counteract the effect of gravity. The longer and more often you go without a bra, the more quickly you are likely to sag.

How long does it take for breast implants to drop with submuscular placement?

It takes time to heal from breast augmentation surgery. Depending on the surface of your breast implants, their size, and your muscle tone, the time to heal and the time for your breast implants to drop can vary considerably. Usually, smooth breast implants placed submuscularly will drop between one to six months after breast augmentation surgery, generally by the fourth month. If they still haven't dropped by the sixth month, a reoperation may be necessary.

More Breast Enlargement FAQs

• Understanding Breast Implants
• Breast Implant Incision Questions
• Health & Pregnancy Questions
• Breast Implant Surgery Questions
• After Breast Enlargement Surgery Questions
• When Can I... Questions

Breast Cosmetic Surgery Information

• Read an excerpt from Dr. Pittman–Waller's book The New Breast Book: New Breasts for a New Look and a New Outlook

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Breast Augmentation – Breast Lift (Mastopexy) – Breast Reduction