When selecting a plastic surgeon for breast augmentation, it is good to know his or her philosophy regarding the optimal approach to placement of the breast implant, and type of implant. There are two main options in selection of the pocket into which the implant is placed, and they can have a significant impact on the result. The plane that has been most popular in the United States is the pocket underneath the pectoral muscle. The other option, which has become more popular in recent years, has been to place the implant under the breast, in front of the pectoral muscle. Another factor is implant type: textured or smooth. My preferred approach is pre-pectoral, smooth cohesive gel implants.
What are the reasons for Sub-Muscular Placement?
It is important to know the underlying reasons for sub-muscular placement. Historically, breast implants were prone to rippling, due to the non-cohesive nature of the implant contents. This resulted in a less than optimal appearance if the patient had thin tissues of the upper pole of the breasts. To camouflage this rippling, the pectoral muscle is lifted from the rib cage, and the implant is tucked under the muscle. This approach is not without its draw backs. Namely, when the muscle is flexed, the breasts twitch quite noticeably. Also, the action of the muscle can cause lateral and inferior displacement of the implant over time, resulting in an un-natural appearance. Another reason that sub muscular placement was favored is due to studies indicating that this pocket is less prone to capsular contracture. In subsequent studies, it has become clear that one of the major effects of sub muscular placement is that it disguises contracture, but does not reduce the true rate of tight capsules. Other factors that contribute to reduced capsular contracture rate have been found to be important. The factors are minimal touch technique, immaculate precise pocket dissection, protection of implant from touching the breast or nipple as it is being placed, and careful attention to controlling blood loss. Recent studies have found that if these factors are optimized, the rate of capsular contracture between the two approaches is not significant. Plastic and Reconstructive Surgery: August 2013 – Volume 132 – Issue 2 – p 295–303.
So…what makes you decide on a specific type of implant?
This brings us to implant choice: textured versus smooth. The rationale of texturing is that texture increases the surface area of the implant, and is thought to decrease capsular contracture. Another reason to texture the implants is to prevent mal-rotation of anatomically shaped implants. Anatomically shaped implants, also known as “tear drop” shaped implants are full on the bottom, and taper as they approach the upper pole of the breast. When in place, it is difficult to distinguish a round implant from a shaped implant. It only becomes obvious if the shaped implants rotates so that the bottom is oriented toward the upper pole, resulting in a misshapen breast. Textured implants have been found to be associated with late seroma, a collection of fluid around the implant, as well as rarely causing a potentially deadly cancer called anablastic large cell lymphoma. The risk of cancer has been quoted as being 1/60,000 to 1/3,000. Due to the low risk profile of smooth gel implants, and the consistent reproducible results achieved with implants in front of the muscle, my current practice is to perform an approach under the breast, precise creation of a pocket under the breast but over the muscle, and use of a protective funnel to smoothly introduce the implant with no contact with gloves or skin. The result is a superb breast augmentation with minimal risk.