Implant placement is one of the most debated topics in breast augmentation.
There are some beliefs and practices in medicine and surgery that transcend time, changes in procedures and technology.
A perfect example of this is the practice of preparing skin with antiseptics prior to beginning a surgical procedure. This will always reduce the risk of infection. Improvements in antiseptics may evolve, but no one debates the need for preparing the skin with an agent that kills bacteria.
There are also beliefs and practices in medicine that do not transcend time, changes in procedures and technology. Placement of the implant either below or above the muscle is an example of this.
Some surgeons believe, for example, that one option is better than the other. However, when technology evolves, these same surgeons do not pivot their beliefs and practices to be in line with current information and technology. While being comfortable in how they continue to practice but not evolve is OK, but at the same time, it may no longer be the best available option for the patient.
So lets examine implant placement relative to the pectoralis major muscle.
I have been performing breast augmentation since 1990. Initially we placed the implants above the muscle, but due to issues with earlier implants that are no longer concerns today, capsule contracture rates were high, so placement for most surgeons shifted to below the muscle, where it has remained for many years.
For thirty years, I believed that there was no reason to place an implant above the muscle. Unless a patient had really thick tissue above the muscle, I had concerns about how unnatural the upper breast would appear with a saline or generation five silicone gel implant, such as the Natrelle, Mentor and Sientra, placed above the muscle.
But placement under the muscle came with a price:
Animation deformity – when the pec muscle contracts the implants and breasts move sidewards.
Widened cleavage – the muscle limits how far towards the midline the implants can be placed.
Implant malposition – The constant contraction of the muscle can displace the implants downward and outward. When lying down, the implants fall to the sides.
Longer recovery – Even with the “one day recovery” I helped pioneer for the past twenty years, recovery is still longer than when I place the implants above the muscle.
Why did I still put the implants below the muscle?
I placed implants below the muscle because these issues were not as visible at rest. However, my concern was the creation of a deformity of the upper breast visible in certain styles of clothing.
So what changed my practice? Why am I placing implants above the muscle now?
With sixth-generation Motiva implants, above-the-muscle placement is often ideal.
There is no animation deformity
I can achieve a narrower cleavage.
I do not see the malposition issues I saw previously.
It avoids muscle disruption – Improves recovery and preserves muscle function.
I can maintain natural contours. The upper breast looks beautiful even when there is very minimal tissue to cover the implant. I have attained beautiful, natural results, even in the much older patient with thin, compromised tissue.
I have all but abandoned below the muscle implant placement and now perform traditional breast augmentation above the muscle, more specifically in the subfascial plane.
Most of my breast augmentations now are performed using the Motiva Preservé technique, also above the muscle, in the Breast Preservation plane.
How will I know what I will look like with breast implants? What if I need a lift? The next video explores the use of 3D computerized simulation in breast augmentation surgery.
