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Determining Placement of Breast Implants

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Determining Placement of Breast Implants

Learn more about how the board certified dotor cosmetic plastic surgeon decides how to place the breast implant based on your body type.

breast implant placement info Determining Placement of Breast Implants

Like every other decision about breast implant surgery, the question of whether to place the implant under the muscle or over is the subject of much debate, with confusion and misinformation in every direction.

Suffice it to say that there is no single best method that applies to every patient; the key is to establish priorities based upon individual anatomy, implant type, and several other factors.

Placement of the implant is decided based each patient’s case. A woman’s breast is a soft tissue that extends over the muscles of the upper chest. The breast comprises a complex group of tissues, including glandular, fatty, and fibrous tissues.

Breast Anatomy

breast anatomy Determining Placement of Breast ImplantsThe breast is positioned over the pectoral muscles of the chest wall and is attached to the chest wall by fibrous strands called Cooper’s ligaments. The fatty tissue in the breast is what gives the breast the soft consistency. This tissue extends throughout the breasts, surrounding the glands and fibrous tissues.

Two groups of muscles behind the breast are the pectoralis major and pectoralis minor. The pectoralis major muscles makes up most of the layer of muscle beneath the breast tissue. The muscle is shaped like an oriental fan, with the gathered part attaching to the upper arm bone and the outer edge attaching to the sternum, or breast bone, and the ribs. Since it is only attached to the chest wall around the edge, there is a potential space beneath it where an implant can be placed. The pectoralis minor muscles attach to the shoulder blade (scapula) and stretch down to the ribs.

The abdominal muscles stretch from the lower stomach to the middle of the chest. The serratus muscles extend from the front surface of the ribs to the shoulder blade. The muscle fascia is the covering for the muscle tissues.

Breast Implant Placement Terms

Placement of breast implants is performed in two methods:

  • Subgrandular Placment: Breast implants placed under your natural breast tissue, which is called either subglandular (located under the breast gland) or over the muscle placement
  • Submuscular Placement: Breast implants placed under the pectoral muscles, called submuscular or under the muscle.

These locations are frequently just called overs and unders. A full submuscular placement is a variation on unders, with the implant placed under the pectoral muscles and other muscles and tissue as well. With partial sub-muscular placement, the upper 2/3 of the implant are behind the pectoral (chest) muscle. The lower 1/3 of the implant is not covered by the muscle. It is located behind the breast tissue.

Subglandular Breast Implant Placement

breast augmentation sub glandular Determining Placement of Breast ImplantsWhen the implant is placed in front of (above) the muscle, that is usually called subglandular, since the breast is a gland.

With subglandular breast implants there is an increased chance of your (or someone else) being able to feel or see the implant. The edges of your implants may be apparent if you have little or no natural breast tissue, little body fat, and thin skin. However, some women prefer a high and tight look to their implants that can be achieved with overs placement.

One advantage of subglandular breast implants, is that this placement can be a quick fix for mild cases of breast sagging (ptosis). However, it will not lift a breast that is sagging significantly, so if the plastic surgeon suggests a breast lift, you should listen. Another advantage is that there is less pain postoperatively and a shorter healing time because the chest muscles have not been disturbed or rearranged during surgery.

Breast implant placement over the muscle also gives a more natural movement as you walk or use your chest muscles. With implants under the pectoral muscle, the muscle will squeeze or contract around the implant as the muscles are used. These movements can make the subpectoral breast implants look unnatural or twitchy, especially if you are doing something like lifting yourself into a boat, out of a pool, or onto a table and or while you are lifting weights.

Submuscular Breast Implant Placement

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.

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, however are rare.

Possible risk and disadvantages of submuscular augmentation are:

  • 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

breast augmentation sub muscular Determining Placement of Breast ImplantsThe 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.

When the implant is below (behind) the pectoral muscle, it may be called subpectoral or submuscular.

breast augmentation submuscular Determining Placement of Breast ImplantsThe term total submuscular is used when other muscles on the chest wall are raised in order to cover the sections of the implant that the pectoral muscle doesn’t. Specifically these areas are on the outside (lateral) and the lower portion. Typically, the pectoral muscle covers about the upper two thirds of an implant. There are potential advantages to having total submuscular coverage but no agreement among plastic surgeons as to whether or not it is practical to do this in every case.

Implants placed completely beneath the muscle are NOT totally behind the pectoral muscles. The top 2/3 of the implant is behind the pectoral muscles and serratus muscles, and the lower 1/3 is behind the fascia, which is the connective tissue that connects the pectoral, serratus, and upper rectus abdominal muscles. Having the implants completely beneath the pectoral muscles ALONE is not anatomically possible.

There are rumors that complete sub-muscular placement is not possible no matter how the surgeon performs the surgery. This is simply not true, and don’t let anyone tell you otherwise.

Complete sub-muscular placement can be achieved via the transaxillary, periareolar, or inframammary fold incision. However, when going with the transaxillary incision, the muscles and fascia can be left in tact. They do not have to be cut or dissected in any way. This is not so with the periareolar and crease incision. With these two incisions, the muscle must be dissected in one way or another, in order to place the implant behind it. Of course, there is the method of simply cutting, and afterwards, it is closed up with sutures, or allowed to heal on it’s own.

Currently, complete sub-muscular placement is not widely used, though it is gaining increased popularity.

How The Surgeon Determines Placement Implants

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 cannot determine what is best. However, your decision may be influenced by these issues which you can discuss during a consultation.

Breast Implant Mammoplasty Surgery Thailand

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breast implant thailand surgery Determining Placement of Breast Implants

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