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Which is better - under or over the muscle when having a breast lift with augmentation?

Q:

I am having a breast lift with small saline implants.  My doctor says that I have enough breast tissue to have the implants placed above the muscle.  I am concerned due to the rippling and capsular constriction possibilities that I have read about.  Is his advice correct in my case?  Please advise.

A:

There are different philosophies about the position of implant placement. My practice is to place implants almost 100% of the time under the muscle because it provides better coverage and a more natural shape. The classic answer is that if you have 2cm of pinch thickness in the upper breasts your implants can be above the muscle. This is a decision best made between you and your plastic surgeon with all of your questions answered. I wish you well!

M.C. Edwards, MD

A:

Breast lift (mastopexy) surgery works well for patients who have enough existing breast tissue which allows the surgeon to build a projecting and aesthetically pleasing breast, and who do not have a severely deflated appearance from pregnancy or weight loss. In many patients, however, it can be difficult to create substantial, long-lasting fullness in the upper aspect of the breasts and the cleavage area, (which surgeons sometimes refer to as the upper poles of the breasts) by means of a routine mastopexy surgery alone. This is particularly true in patients who have experienced significant deflation following pregnancy and lactation, and in patients who have experienced major weight loss.

This need for increasing upper pole fullness can be accomplished in one of two ways: by using the patient's own lower pole breast tissue (auto-augmentation mastopexy), or by placing a breast implant. Auto-augmentation mastopexy is a surgery in which some of the patient's own lower pole breast tissue (from the area of the breast below the nipple/areola complex) is moved into the upper pole of the breast. A pocket is created behind the upper pole of the breast and the lower pole tissue is advanced, with its blood supply intact, into the upper pole pocket. This truly remarkable procedure can create a mastopexy appearance that previously has only been possible by means of breast implant placement. Not all patients are good candidates for this procedure, as there must be an adequate volume of lower pole tissue available to produce significant upper pole (cleavage area) breast fullness. Most patients undergoing auto-augmentation mastopexy in this practice have a full B cup to D cup breast volume preoperatively.

For patients who do not have enough lower pole tissue available to allow an aesthetically ideal auto-augmentation mastopexy, or for patients who desire a larger breast volume than can be achieved by use of their own tissues, I recommend that they undergo breast augmentation mastopexy. This surgery combines a breast lift with the subpectoral placement of breast implants usually of a moderate size, which produces lasting upper pole fullness. This procedure is often the ideal choice for patients with an A cup or small B cup of breast volume preoperatively, who are interested in having a C to D cup breast profile postoperatively This surgery is a potentially challenging one which requires thoughtful preoperative evaluation and planning, and careful attention to detail in the operating room.

This may be a somewhat controversial statement, but in my opinion there currently is really only one acceptable position for breast implants in an elective cosmetic surgery patient: behind the pectoralis major muscle (sub-pectoral augmentation). There are a number of very compelling reasons to place implants behind the pec major, and the most compelling one of all is the fact that radiologists report that the mammographic imaging of breasts for the purpose of breast cancer screening tends to be more easily accomplished when breast implants are sub-pectoral (compared to pre-pectoral, also referred to as the sub-mammary position). An American woman's current lifetime risk of breast cancer is approximately 1 in 8 to 1 in 9, so the issue of breast cancer screening must be taken very seriously. Mammography is by no means a perfect screening study, but it is the standard of care at this point in time. The most sensitive and specific test for breast cancer is a contrast-enhanced MRI scan, and breast implants do not impair breast tissue visualization by MRI.

The next very compelling reason to select sub-pectoral placement is a cosmetic one. Implants placed on top of the pec major tend to stand out in the upper pole of the breast, creating a rounded, convex and distinctly unnatural-appearing breast profile. With implants in a sub-pectoral position, the upper pole of the implant is flattened somewhat by the muscle, helping to create a smooth transition from the area in the upper chest where the breast begins, and a gradual slope towards the nipple that is not excessively rounded or convex. In some patients with a fuller breast volume preoperatively one may get an acceptable appearance with pre-pectoral placement - initially. The problem is that as breasts age, the fatty tissue atrophies and breast tissue thins out, and the area where this is most obvious is in the upper pole and cleavage area. So a pre-pectoral implant that was initially well-concealed may, after a few years, become painfully obvious (including visible implant folds and ripples) in the upper pole.

Many surgeons have traditionally performed breast augmentation and mastopexy surgery in stages, usually mastopexy first followed by augmentation at a later date. In the recent past more and more surgeons have adopted a non-staged, single surgery approach to augmentation and mastopexy, and that is what I propose for the vast majority of patients who I see in consultation that need both procedures. I believe that the results of simultaneous augmentation mastopexy are as good or better than a staged approach in most cases, and of course patients quite naturally prefer a single trip to the operating room if at all possible.

M.M. Law, MD

A:

Placement of breast implants during breast augmentation/lift is dependent on the experience of the Plastic Surgeon. If you have enough superior breast tissue, and most people do, I like to place the implants over the muscle. This allows me to move the breast tissue up easier and give a better lift. There is no sacrifice of shape or of hiding the implant. If you are active and use your arms a lot, it also prevents the breasts from bouncing when you move your arms. There is additionally some evidence that it reduces implant rupture and displacement.

R.T. Buchanan, MD

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