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What kind of implants are best for breast augmentation, placed under or over the muscle, and how natural will they look?

Q:

I want to have breast augmentation.  What kind of implants are best, and what way is best to perform the surgery (over or under the muscle)?  How natural will they look?  Is there a risk that my nipples will become smaller with the augmentation?

A:

The type of implant is controversial. Saline costs less but has more ripples generally. The smooth silicone implants are by far the most used in the United States today. There is the newer gummy bear implants that are textured and we hope will last longer, but we don't know that yet. It is a fact that implants put on top of the muscle have a much higher complication rate than those put under the muscle, especially with capsular contractures (nationwide 10% under the muscle vs 30% if over the muscle). You should go over your choices with your ASAPS plastic surgeon as he is Board Certified, and does more Aesthetic (Cosmetic) surgery.

Usually the shape of your breast with implants looks just like the shape you have now, just larger.

The areola will usually become a bit larger with augmentation as it stretches the skin out - less with under the muscle than over the muscle, but bigger always. Never smaller! Good luck with your search.

Dan C. Mills, II, MD

A:

An implant placed above the muscle is referred to as sub-mammary (or sub-glandular), while an implant placed under the muscle is referred to as sub-pectoral (or sub-muscular). The muscle in question is the pectoralis major. The term sub-pectoral or sub-muscular is somewhat misleading, as implants placed under the pec major are only partially covered by the muscle. The pec major covers the upper/medial half of the breast area, so a sub-pectoral implant is truly subpectoral only in the upper and medial aspect of the augmented breast, while the lower and lateral aspect of the implant is actually in a sub-mammary position. Because sub-pectoral implants are, in reality, both sub-pectoral (upper/medial breast) and sub-mammary (lower/lateral breast), this placement has more recently been referred to as a dual plane approach to breast augmentation.

There is also total submuscular implant placement, in which the implant is positioned behind the pec major and the serratus anterior muscle, so that the entire implant surface is covered by muscle tissue. This is not commonly done for cosmetic breast augmentations, but has been used for breast reconstruction using breast implants.

There are a number of compelling reasons for selecting subpectoral placement over submammary placement. The most significant is the fact that radiologists have indicated that it is easier to image breast tissue by means of mammography when the implant is subpectoral. The pec major also provides an additional layer of tissue to conceal breast implants in the social aspect of the breasts -that part that is easily visible in swimsuits and lower-cut clothing. Additionally, the pec major is quite effective at flattening the upper pole of a breast implant so that a natural slope for the upper aspect of the breast is created.

Implants placed on top of the pec major tend to look very convex in the upper pole. The breast begins quite abruptly in the upper aspect of the chest, and the appearance is therefore distinctly unnatural. Submammary implants are also more likely to have visible implant folds and ripples in the cleavage area. Another consideration is the fact that there is some evidence which suggests that the risk of capsular contracture may be lower with subpectoral implant placement. Even if the risk of contracture is the same, a mild contracture tends to be less noticeable and therefore less of a problem for the patient when the implants are in a subpectoral position.

Submammary placement may produce a reasonable result for fuller figured patients with larger starting breast volumes, as the larger amount of natural subcutaneous fat and breast tissue helps to conceal the implant contours. The problem is that as breasts age, they tend to deflate - especially in the upper pole. So what was adequate implant coverage in the cleavage area at age 27 may be inadequate coverage at age 37, and implant folds and ripples gradually become visible. So subpectoral placement is the best choice for both the short and long term.

Sub-fascial breast augmentation is also possible. Fascia is the term for a sheet of connective tissue made of collagen, and the pec major has a fascial covering as most muscles do. Breast implants can be placed behind the pec major fascia only, rather than behind the entire muscle, however this approach is not widely used. The pec major fascia is a relatively thin layer of tissue, so it is not nearly as effective in concealing breast implants as the actual muscle itself. Partial sub-fascial placement can be useful in some breast augmentation revision surgeries, where variations in pec major origin or incorrect release of the pec major has resulted in significant distortion of breast appearance when the muscle contracts.

Yes, augmented breasts can and should look natural. With the right implant in the correct position, they can also feel completely natural. Excessively large breast implants never look or feel natural, so the first important factor to consider is implant size. Not only do large implants look odd, they also stretch out breast skin and tend to become very droopy over time. Most patients with excessively large implants end up having multiple operations over time to address problems with implant position (bottoming out for example, where implants drop below the desired level of the inframammary fold), implant visibility, and overstretched skin. If the goal is a natural-appearing breast augmentation, then most patients will require an implant volume between 250cc and 450cc. A petite patient looking for a B-cup to C-cup transition may need a 275cc implant for example, while a tall, broad-shouldered patient looking for an A-cup to C-cup transition may require a 425cc implant.

A common error that leads to an unnatural appearance after breast augmentation, even with implants of an ideal size, is inadequate lower pole dissection and/or inadequate release of the pectoralis major origin just above the inframammary fold. As a result the implants sit too high and appear excessively full in the upper poles (the area above the nipple-areola complex), while the lower poles - which should be the fullest area of the breast - are underfilled. Inadequate muscle release may also result in bizarre-appearing breast implant animation when the pec major muscle contracts. In some cases this may result in one or both of their implants jumping up literally to the level of a patient's collarbones - an alarmingly unnatural look, and one that is totally avoidable.

Most patients want to have the fullest breast profile that still looks natural on their body. The limiting factor for implant size is almost always the appearance of the upper pole. At some implant volume, the upper pole of the breast begins to look excessively rounded or convex, and that is a look that says breast implants live here. There really is no way to determine preoperatively what the fullest implant volume is for each patient that does not produce that rounded upper pole look. The only way to accurately make this decision is to use breast implant sizers intra-operatively, and to evaluate them with the patient sitting fully upright in the operating room during the surgery. Surgeons who are attentive to detail use an O.R. table which allows them to sit a patient upright several times over the course of the procedure, so that an implant size and profile can be selected that is ideal for each individual patient.

The type of implant is also important, as the implant style that will work best to produce a natural feeling result depends on a patient's body style and preoperative breast size. Silicone gel implants, without question, have a much more natural feel than saline implants in slender patients, especially those with an A-cup or small B-cup preop breast profile. On the other hand, fuller-figured patients with a full B-cup breast size that are seeking a full C- or a D-cup breast enhancement will almost always get a breast augmentation result that feels completely natural if saline implants are used. The more natural tissue there is to conceal a pair of implants, the harder it is to detect saline implants by feel.

M.M. Law, MD

A:

The best implant for each patient is dependent on individual factors. Options for placement include under the muscle (the vast majority), a variation called split muscle technique that minimizes "animation deformities", subfascial, and subglandular. The choice depends to a degree on how mush tissue (fat and breast) is available to cover the implant. Implant types are saline, cohesive silicone gel, or form-stable or "shaped" implants. Most implants in the U.S. are round gel.

Richard A. Baxter, M.D. - View Other Answers by this Doctor
Mountlake Terrace, WA

A:

Chelsea,

Thank you for your question. Most surgeons prefer to place breast implants under the muscle if possible. However depending on your breast shape and the amount of sag, a breast lift may be necessary to place implants under the muscle. For patients who do not want a lift, in some cases the breast implant may be placed under the gland and over the muscle.

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