Can you please explain the differences in procedure, recovery time and effect between...
Breast augmentation requires the placement of an implant through a small incision beneath the breast tissue to enhance the shape of the breast. The implant may be placed directly beneath the glandular tissue (subglandular) or beneath the glandular tissue of the breast and beneath the pectoralis major muscle just beneath the breast (submuscular). As a general rule, implants that are placed below the muscle result in slightly more discomfort postoperatively. However, this discomfort is easily controlled with pain medication in the typical patient. Submuscular implants have more tissue between the implant and the skin (muscle + breast) than those placed below the glandular tissue alone. The appearance is slightly different from implants placed subglandularly, so you may want to look at pre- and postoperative photos. It is generally felt that placement of the implant under the muscle makes it easier to obtain a good-quality mammographic x-ray of the breast. However, women who work out a lot may feel that placement of the implant under the muscle gives the breast an unnatural appearance when lifting weights. As to which approach is superior, it is up to the patient and her plastic surgeon to discuss the pros and cons of each and to make the best choice for the individual patient based on anatomy, the surgeon’s experience and the patient’s desires.
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.
'Under the muscle' and 'sub-pectoral' are actually somewhat misleading terms, as in most cases the implant is only partially subpectoral. The anatomy of the pectoralis major muscle is such that it is actually just the upper/medial half of the implant that is covered by the muscle, while the lower/lateral half of the implant is submammary. The pectoralis major thus provides an additional layer of tissue to conceal the implant in the most cosmetically significant area of the breast: the cleavage area. This is why saline implants are often easy to feel laterally, as they are covered by breast tissue only in lateral aspect of the breast, and in slender patients who have small breasts preoperatively the implant is often immediately under the skin in this area.
Sub-glandular breast augmentation is a procedure in which the breast implant is placed on top of the chest muscle beneath the breast gland. Recovery is much quicker after Sub-glandular breast augmentation and achievement of final shape occurs much more rapidly. However breast implants placed beneath the gland on top of the muscle can be more visible and have a higher incidence of capsular contraction or hardening of the breast implant.
Sub-muscular breast augmentation places the breast implant beneath the chest muscle. Although recovery may take a few days longer most surgeons today prefer to do a sub-muscular approach. By placing the breast implant beneath the chest muscle the coverage of the implant is thicker and better which provides less risk of visible implant irregularities. Most importantly the risk of capsular contraction or hardening of the implant is less when placed beneath the muscle. Some studies have shown in the mammograms are more complete when the implant is placed beneath the chest muscle.
There are two choices for breast implant placement: sub-glandular (under the breast tissue and in front of the chest muscle – the pectoralis muscle) or sub-muscular (under or partially under the chest muscle). The best location depends on many factors including: tissue thickness, weight, desired outcome, and individual anatomy. Each position has advantages and disadvantages:
Subglandular implant benefits:
- A shorter recovery time.
- Less discomfort initially.
- No distortion of the breast when the pectoralis muscle flexes.
- Mild preoperative sagging can be improved, especially if no breast lifting procedure is performed.
- Easier surgical procedure.
- Larger implants can be placed.
Subglandular implant disadvantages:
- The implant may be more visible.
- More visible rippling, especially in patients with a small amount of natural breast tissue.
- Generally, saline implants do not produce a good result in front of the muscle.
- Higher incidence of capsular contraction.
- “Bottoming out” in some patients.
- Some radiologists have more problems reading a mammogram with an implant in front of the muscle.
Submuscular implant benefits:
- Usually results in a better appearance for naturally small breasted women
- Less tendency for seeing ripples of the implant.
- A more natural feel to the breast especially in slender women who don’t have much of their own breast tissue.
- Less interference with mammograms, although most radiologists take additional views no matter where the implants are placed.
- Lower rate of capsular contraction.
- Less of a chance of “bottoming out” where the implant bulges at the lower aspect of the breast and the nipple and areolas tend to appear excessively elevated.
Submuscular implant disadvantages:
- Recovery usually takes a little longer and is more uncomfortable initially.
- There may be an “animation deformity”, which is a temporary distortion of the breasts when the pectoralis muscle is flexed. Body builders and weight lifters generally prefer implants in front of the muscle.
- It is harder to achieve cleavage in women who have widely spaced breasts.
- The implants often ride higher on the chest.
Actually, most patients who have breast augmentations today have breast implants placed in a combination or “dual plane” position. This approach has the same benefits and disadvantages of a total “submuscular implant”, but with a lesser tendency to ride high on the chest wall. The disadvantage as compared to a total “submuscular implant” is a higher tendency for bottoming out.
The ideal placement in any particular patient depends on their particular anatomy and understanding of the pros and cons of each approach.
Keep in mind, that following the advice from a surgeon on this or any other website who proposes to tell you what to do without examining you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of each operative procedure may not be in your best interest. I would suggest you find a plastic surgeon certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person.
Robert Singer, MD FACS
La Jolla, California