Breast implants are placed into a pocket under the breast. The terms “above the muscle” and “below the muscle” are frequently bandied about. Which is better? Patients have opinions, surgeons have opinions. Certainly, I, a plastic surgeon who has performed a fair number of breast augmentations, have an opinion. Before I render than opinion, let’s review the pertinent anatomy.

Below the breast is the pectoralis major muscle. It is attached to the chest wall along the lower, inner portion of the breast, then along the entire side of the breast bone. The muscle spans across the chest like a triangle, and attached to the upper arm bone called the humerus. Below the muscle lies the chest wall, essentially the rib cage.

To place the implant under the muscle, a pocket is created by lifting the muscle off the underlying rib cage. The attachment of the muscle to the overlying breast remains undisturbed. To place the implant above the muscle, the breast is lifted off the underlying muscle. The attachment of the muscle to the underlying rib cage is undisturbed.

So, which is better? In either case, you have a pocket, and in that pocket you increase the size of the breast by inserting an implant. Theoretically, it should not make much difference. Theoretically yes, but in practice, quite the opposite. Consider the following:

1. The more soft tissue (breast and muscle are both examples of “soft tissue”) that is placed over the implant, the less visible and palpable the implant will be. If the patient has nice, thick, firm breast tissue, then it may not make too much difference which route you take. Certainly, if the tissue is naturally thin, or thinned out by atrophy after pregnancy and lactation, if will matter greatly which route of placement is utilized. Also, consider that with time, everyone (unfortunately) ages and that results in thinning (atrophy) of tissue.

2. The muscle is subject to less stretching that the skin and breast tissue. It acts like a stabilizer to prevent overstretching of the breast pocket (to some extent).

3. There is (according to my friends who are radiologists specializing in breast imaging) less interference with interpreting mammography when the implant is below the muscle. This statement is purely anecdotal and not based on any personal experience as I do not interpret mammograms.

4. It is no easier to place the implant above the muscle than below it, and probably requires a little more surgical effort, although not enough to make any difference to persuade the surgeon to choose below the muscle placement.

5. Despite the fact that the muscle is being partially cut with placement below the muscle, I do not believe that there is any more discomfort or downtime in using below the muscle placement. I utilize a rapid recovery method with below the muscle placement and my patients require no more than Advil for discomfort and are driving the next day.

So then, what is the reason surgeons choose to place implants above the muscle? There are a few reasons. The first may seem silly, but is in fact a reason surgeons choose to do what they do. The answer is “because that is what I was taught to do”, or “because that is how I have always done it and it works for me”. That is fine, but you cannot advance as a surgeon if you don’t keep yourself open to advances. Personally, I am always on the lookout for better ways to do things. It may take some getting used to when changing up to another technique, but if it is for the betterment of my patients, then why not? If I wasn’t progressive, then I would still be writing prescriptions for narcotics like Vicodin instead of just Advil after surgery, wrapping my patients is straps and bandages instead of just a small paper Steri-Strip and telling my patients they cannot raise their arms or drive for days or weeks instead of raising their arms high above their head while still on the recovery room stretcher and driving to their first follow up visit in my office the next day. That is a whole different story; my point is that a surgeon must be up to date on the latest techniques and methods.

There is one compelling reason why many surgeons place implants above the muscle. If you have a breast that has lactated, lost fullness in the upper portion and the glandular tissue is bottoming out (some of the breast tissue lies below the lower crease of the breast), then you have a special situation, one which is also very common. If you place an implant below the muscle, then the breast mound from the implant will lie up high, but the breast tissue will slide off the front of the implant and sag over the implant. From the side, this resembles the side view of the dog “Snoopy” from the Charlie Brown cartoons. The reason for this is that the muscle is preventing the implant from moving lower into the breast where there is some sagging. If you place the implant on top of the muscle, then you no longer have this problem. However, placing the implant above the muscle will result in some other potential problems: there is now much thinner tissue over the implant, so the implant will be more palpable and visible. Also, there will be less support of the shape of the breast without the muscle. Lastly, mammography may be more difficult.

A better solution is to place the implant under the muscle using a dual plane technique. In this technique, the muscle is repositioned superiorly in the breast pocket. There is a little less muscle coverage of the implant, but there still is muscle coverage of the upper portion of the implant nonetheless. The implant can now move into the lower pole (portion) of the breast and fill it out properly. All this with no need for a breast lift.

The dual plane technique will be the subject of a future blog on this website.

In November, 2006, silicone gel filled implants were approved by the Food and Drug Administration (FDA) for use in women twenty two years of age and older. Along with this announcement came an interesting recommendation: routine MRI (Magnetic Resonance Imaging) to surveil for implant rupture. Why this new recommendation? Saline implants are prone to device failure just as is a silicone gel implant. After all, the silicone shell of both saline and silicone gel filled implants are identical. Furthermore, saline implants have a valve that silicone implants do not have and this is prone to failure (and leakage) as well. The difference is that if a saline implant leaks, the device will deflate in about 48 hours and there will be a very noticeable difference in breast contour and loss of volume. The saline is absorbed. Saline is nothing more than salt water, a normal component of our bodies. With silicone gel filled implants, on the other hand, should a small defect occur in the implant shell, the silicone will by its cohesive nature most likely remain inside the implant. If a more significant compromise occurs to the implant shell, such as a tear, the silicone gel will be contained by the scar tissue capsule that forms around all breast implants, silicone and saline. There may or may not be any appreciable difference in the breast appearance and feel. There may or may not be some discomfort in the breast. As many of such device failures are asymptomatic, the FDA believes that there should be some type of routine screening for such a situation. MRI’s are ideal for identifying a defect in the breast implant. Although not perfect, they are fairly accurate and do not involve the use of ionizing radiation as is the case with a mammogram and CAT (computerized axial tomography) scan.

The current FDA recommendation is to obtain a MRI examination of the breasts three years after breast augmentation surgery and every two years thereafter. Does this make sense? To put it simply, there will be a certain amount of women who will experience device failure of a silicone gel implant. If you screen everyone every year, then almost all of these problems should be picked up by the MRI scan. If you screen no one, then of course, there will be none of these problems identified. So then, what frequency of examination makes sense? Just like screening for any disease or problem, you have to have an understanding of the actual frequency the problem, the severity of the problem (is it life threatening or a risk to quality of life or the health of the community vs. low health risk) and the costs of the screening program. Most likely, a screening program will not screen everyone each year, which leads to some problems going unrecognized. The other question is: What is the consequence of not recognizing the problem? Will there be a compromise to one’s life, health, livelihood or their family? In the case of breast implants, if a rupture is missed, there is most likely not going to be a significant risk to the patient’s health. Silicone is biologically inert and fifteen years of studying breast implants have demonstrated that they are not a causative factor in the development of any systemic diseases.

The first question is whether or not an MRI, which is an expensive test, is an appropriate first line screening test for breast implant rupture. In screening for cancer, mammogram remains the gold standard for initial screening. If there are any abnormalities seen, then it is ultrasound, not MRI that is used next to investigate further. This is not because MRI is inferior to ultrasound, but rather than ultrasound is a good second screening test and is much more cost effective then proceeding directly to an MRI. Should there still be some question after ultrasound, an MRI may be a good way to go prior to considering surgery in cases where there exists uncertainty as to whether or not a problem exists within the breast. I have found this process to be extremely useful in my cosmetic breast surgery patients (augmentation, lift, reduction) who require routine screening prior to commencing surgery. So why then, is MRI recommended as the initial screening tool for a silicone breast implant rupture? Is it better than less expensive tests?

In an excellent 1998 scientific study at the University of Michigan, Chung found that if ultrasound was the initial screening tool for a breast implant rupture and the ultrasound test was read as normal, the chance of a false negative, in other words, the chance that the normal interpretation of the ultrasound was incorrect and that there really was a rupture which was undetected was only 2.2%. On the other hand, if ultrasound did suggest a rupture, and an MRI was obtained afterwards which also supported a diagnosis of implant rupture, then there was an 86% chance that the implant was in fact truly ruptured. This is a high enough chance of rupture to support the plan of surgical exploration and implant replacement if a true rupture is actually found.

In a separate study in 2001, Cher found that in women with breast implants who have a specific complaint referable to the breast such as pain, capsular contracture or a change in the appearance of the breast, an MRI is better than 80% accurate in predicting an implant rupture. In the absence of such symptoms, the predictive value of MRI is much less, and was not felt to warrant use as a routine screening method for implant rupture in such asymptomatic women. The Royal College of Radiologists in the United Kingdom stated that ultrasound is 91% accurate if it demonstrates an intact implant, not too dissimilar to the results of the University of Michigan study discussed above. Furthermore, they concluded that the initial screening tool should be an ultrasound, followed by MRI (preferably one with a dedicated breast coil and a magnet strength greater than 1.5 Tesla) if the ultrasound suggests a rupture of the implant.

How often does rupture really occur? I use the rough rule of thumb of about 0.5 to 1% per implant, per year. Mentor’s core study of 420 patients demonstrated a 0.5% rupture rate at three years out from surgery, but there have been other studies that don’t show ruptures for even up to seven years (Sharpe and Collis- UK). Does it make sense to have 199 women to undergo MRI to find one rupture (assuming a 0.5% rupture rate)?

So, should one follow the current FDA recommendation and obtain an initial MRI examination of the breasts three years after breast augmentation surgery and again every two years thereafter?

- Consider that as third party payers (your health insurer) have strict clinical guidelines for the authorization of a breast MRI, it is quite possible that these routine MRI’s in an asymptomatic patient may not be paid for by health insurance.
- Consider the fact that a missed implant rupture is highly unlikely to represent a health risk to the individual.

- Consider that a normal ultrasound demonstrating an intact implant is better than 90% accurate

- Consider that the rupture rate is approximately 0.5% after three years.

My personal opinion, based on the information given above, is that the FDA guidelines represent overkill. In other words, I believe that these recomendations are not cost effective, and probably counterproductive. What I mean by stating that the FDA’s recommendations are not cost effective is that less expensive ultrasound is highly effective as a screening tool for implant rupture and given the fact that breast implant rupture occurs with such a low frequency brings into question the relatively frequent intervals that the FDA is recommending for breast surveillance for implant rupture. What I mean by counterproductive is that if the MRI’s are not covered by health insurance (unless there is a clinical problem, and even then possibly only after a mammogram and ultrasound have first been performed) I would not expect most women with breast implants to voluntarily follow these guidelines for cost reasons alone, as they may have to bear the financial burden of these costs. Therefore, less, if not more women will undergo such routine surveillance, which is the opposite of the FDA’s intended goals. I do not know what scientific rationale was used to develop the FDA recommendations, however, based on current scientific data, the FDA recommendations are not supported. The FDA’s recommendations are only just that, “recommendations”, not law and it is up to the individual patient to decide how to use this information. I feel that it is my obligation to present not only the FDA’s position, but my own as well.

The good news for women undergoing breast augmentation with silicone gel implants is is that breast ultrasound, a much less expensive option, is readily available for those women who are interested in routine surveillance of their breast implants. Breast ultrasound is also not “rationed” by third party payers as are breast MRI examinations.

I performed my first breast augmentation in 1990. Over the years a great deal has changed with regard to the approach to this operation. Some surgeons still take the same approach they did twenty years ago. Others, like myself, try to stay current and even set the standard for the procedure (i.e. 24 hour rapid recovery technique)

I have been amazed that patients are still asking the question: When do I need to change my implants? Breast implants are mechanical devices and as such are prone to failure at some point in the future. The question is when. I remember several years ago removing a ruptured saline implant from a woman that was placed sometime in the mid-1970’s. I was amazed that this device, which looked like it was made out of a plastic baggie in comparison to today’s sturdily constructed implants (alright, a little bit of a gross exaggeration!), lasted twenty five years inside this woman’s body before it failed. The fact is, unless I can develop clairvoyant powers and predicts the future, I cannot answer this question. Let me explain. To put it very simply, and understand this is just my opinion, “if you are happy with your breasts then you do not need to change your implants unless you are having a problem.” The following is a list, not necessarily all-inclusive, but a list nonetheless of the reasons that I think a woman should consider revision breast implant surgery:

1. Deflation of a saline implant: If you have a saline implant, then any leak, whether in the silicone shell (the bag itself) or in the valve used to fill the implant, will result in a gradual deflation which will probably take about two days to occur. You will then notice a marked difference in the size of your breasts. No further diagnostic testing is required; you simply need to remove the implant. Your options are to replace it with a similar device, replace both implants with similar devices (if the implants have been in place for several years – this is arbitrary – maybe 8 – 10 years or so), replace the implants with saline implants of a different size if you are having issues with the size or replace both implants with silicone gel implants for a more natural feel to the breasts.
2. Rupture of a silicone gel implant: Rupture of a silicone gel implant is a bit harder to diagnose. With regard to the more recent implants, a small hole in the implant will most likely not leak any silicone gel due to the cohesive properties of today’s implants. If there is a tear in the implant shell, then the silicone will be contained by the natural scar tissue “capsule” that forms around all foreign bodies implanted inside us (a breast implant is a kind of foreign body). Silicone is biologically inert, which means that it won’t react with our bodies in an untoward and dangerous manner. Because the silicone is not absorbed by our bodies (nor does it travel elsewhere in our bodies), the breast will most likely look at feel the same even though the device is compromised. For this reason, the FDA recommends getting breast MRI’s at three years after surgery and every two years thereafter. Due to the infrequency of rupture, this may not be a very effective use of our health care budget and will be the subject of a future blog.
3. Capsule contracture: In this condition, the breast feels hard and may even be uncomfortable. The implant is not changing. Rather, the scar tissue envelope that forms around the implant thickens and contracts, causing the implant to feel firmer. Treatment involves re-exploring the breast, removing the scar tissue causing the problem and replacing with a fresh implant of the same type and size.
4. Asymmetry / breast deformity: If there is a shape issue of the breast that concerns you, and your surgeon believes that he/she can correct this surgically, then it may be reasonable to proceed. This can include issues relating to the first implant surgery such as improper pocket creation, improper implant selection, issues due to weight loss or pregnancy/lactation, malposition or displacement of the implant, palpability/rippling/wrinkling or visibility of the implant, ptosis (drooping) of the breast, lower (pole) breast over-stretching or changes in body habitus where your breasts now look too large or small for your frame.
5. Desire to change implant size: I am a firm believer that if you want to have the best breast (best looking, most natural in shape) for the longest period of time with the least probability of requiring a revision, then you need to subscribe to the belief that for every breast, there is a specific ideal implant volume that will result in a properly filled, natural appearing breast. If you have attained that now, but wish to go larger, then you are playing with fire. You will risk overstretching your breasts and creating a whole new set of problems, including the development of uncorrectable deformities. If you do not have the proper size implants for your breasts, then revision to a different size (larger or smaller) may be indicated. Your surgeon is best positioned to make that determination.

Capsule contracture and implant deflation/rupture are the most common reasons for implant revision surgery. Ptosis may require a mastopexy (breast lift) and palpability/rippling/wrinkling or visibility of the implant is usually best managed by replacement of the implants (if they are saline) with silicone implants.

Nationwide, the three year revision rate for breast augmentation surgery is about 25%. Who would want to undergo such surgery if there were 1 in 4 chances that you will need a second surgery to fix something in within the next three years? This is simply too high. In my practice, the revision rate is around 1 – 2%. Almost all of these cases are due to device deflation and capsule contracture.

Short of the above, if you are happy with the way your breasts look and feel, and are having no problems with them, then there is no reason to re-operate on them. I hope that this article helps to dispel some of the rumors that have circulated for years about breast augmentation surgery.

Investing in yourself - Cosmetic surgery and Botox in Stony Brook, Long Island

There are many things that we invest in. Most of the time when we think “invest” we envision a plan to take an initial financial commitment and place it somewhere so that it enhances in value. Although worthwhile, there are other great ways to invest your money. We do this all the time and not think about it. We invest money and time in our own education or that of our children so that we (they) can have an enhanced earning capacity to hopefully lead a more comfortable and secure life. We invest time to find the right home, car, vacation. We invest our emotions in finding the perfect spouse. I write this on the day of my eleventh anniversary, for instance. Investing all comes down to making oneself happier and more secure.

Cosmetic surgical procedures such as breast implants, breast lifts, tummy tucks, facelifts, rhinoplasty and liposuction are often seen as a luxury, maybe even frivolous. But when you think of it, it really isn’t. It may help you feel more secure and confident about yourself; more comfortable within your own skin, so to say. And unlike a vacation, a car, a boat, a new entertainment system, the results obtained with cosmetic surgery are longer lasting and appreciate with time. How do you place a value on feeling good about yourself, being more self-confident?

Let’s talk about Botox. An average treatment may run $600 for about 40 – 50 units of Botox. If the Botox treatment lasts, conservatively speaking 90 days (sometimes up to 120 days), the cost per day is about six dollars per day to look younger and more refreshed.

Cosmetic surgery is even more of a value. The most common cosmetic surgical procedure is breast augmentation. The approximate cost of breast implant surgery on Long Island is around $7300.00. Although you never need to change a perfectly good breast implant, device failure is about one percent per year. So at twenty years there is a twenty percent chance of needing to replace a breast implant. So let’s say the duration of the breast implant surgery procedure is twenty years. Twenty years is 7300 days. So for just one dollar per day, you can feel better about yourself. Isn’t that worth it?