Implant Placement

Cosmetic Surgery Magazine article, posted 2005

The breast is a skin appendage supported by, and suspended from the chest wall. The first breast augmentations performed during the 1960s involved the creation of space immediately behind the breast for insertion of an implant. Cosmetic outcomes were excellent except in circumstances of capsular contracture, or hardening of the breast. The search for solutions to this problem led to the development of submuscular augmentation in which the upper portion of the implant was placed under the pectoralis major muscle. Studies performed in the early years suggested there was indeed a diminished rate of hardening among those treated with submuscular technique. However, as time went on and implant technology improved, the data did not continue to show this advantage for submuscular positioning. Today, there is little to suggest that the incidence of capsular contracture relates to implant positioning.

Among the currently proposed advantages of submuscular augmentation are:

  • More natural contour to the upper breast
  • Better mammography
  • Less visible rippling and wrinkling with saline implants
  • Better hidden upper implant edges

With advent of anatomically shaped implants, concerns about excessive roundness in the upper breast pole have been mitigated. Subglandular anatomical augmentations produce natural contours without need of overlying muscle to flatten the upper implant. Additionally, radiologic experts tell us that softness in the breast and proper X-ray technique are the key factors in obtaining quality mammographic studies. Remaining at issue, however, is the ability of each patient’s tissues to mask the upper pole of the implant from view. Arguments can indeed be made that thinner patients obtain better upper pole aesthetics through submuscular implant positioning.

Were there no downside to submuscular implantation, it would make sense that all breast augmentation patients be treated in this fashion. However, significant disadvantages do characterize this technique, including:

  • Greater postoperative pain from muscle cutting
  • Longer recovery
  • Atrophy of lower pectoralis muscle fibers
  • Less lift for the pendulous breast
  • Distortions in breast shape with muscular contraction
  • Greater patient awareness of the implant during exercise

In order to justify subjecting a patient to these disadvantages, one must be convinced that other benefits will be obtained. The extremely thin patient will usually achieve superior results through submuscular implant positioning. This is particularly true for larger volume augmentations. Likewise, the patient previously treated with subglandular augmentation yielding poor upper pole aesthetics will benefit from submuscular conversion. Finally, women with a history of cystic mastopathy and multiple breast biopsies may be reassured that their implants are at less risk for injury during any future biopsies when partial submuscular coverage is obtained.

Subglandular anatomical augmentations produce natural contours without need of overlying muscle to flattenthe upper implant"

Final determination of what implant position is best for each patient must follow a complete evaluation of several factors:

  • The patient’s individual anatomy, including the thickness of her tissues and the degree of pendulousness of the breast
  • The patient’s desire regarding volume increase
  • The patient’s lifestyle, including the exercise routine
  • The patient’s personal history of breast disease

Only by taking all factors into consideration can an appropriate decision regarding implant positioning be made. It is important to note that this decision process should only be guided by the surgeon; the patient herself cannot determine what is best. However, her decision may be influenced by these issues.