Breast implants may be surgically placed behind the breast tissue only, under the pectoralis (chest) muscle or under just the connective tissue layer covering the pectoralis muscle called the muscle fascia. Each of these locations can give excellent cosmetic results, but a single approach is not suitable for every patient. What is perfect for one patient may not be at all appropriate for another. My role as a consultant is to guide patients and recommend the best alternatives to obtain the best possible results.
Placing the breast implant directly behind the breast (ie. behind the breast “gland”) where it lies in front of the pectoralis (chest) muscle is the most traditional and still probably the most commonly used technique for breast augmentation. It is less invasive because the muscle layers are not surgically involved and some patients feel that they experience a quicker recovery than when the implant is placed in front of the chest muscle. If a woman has a fairly substantial thickness of natural breast tissue to conceal the implant, a sub-glandular approach can give excellent results. However, with bigger implants and thinner natural breast tissues, the risk of seeing or feeling the texture of the implant increases. In such patients, the unnatural round ball look can result. For women with thin breast tissues, the sub-glandular approach may not be ideal.
Sub-muscular implant placement involves placing the breast implant behind the pectoral (chest) muscle and against the chest wall. The pectoralis muscle helps to soften the upper contour of the breast, giving it a more gradual slope and avoiding the “beach ball” appearance that can sometimes occur with poor surgical planning. The muscle layer typically covers the upper half of the implant. The lower boundary of the pectoralis muscle does not extend to the lower curvature of the breast so “sub-muscular” implants are really only partially under the muscle.
Placing an implant under the muscle not only improves the contour of the upper half of the breast, but it also supports the implant and helps to hide the edges of the implant so the transition beyond the breast itself is smoother. There is a slightly lower risk of developing capsular contracture (or scar tissue) when the implant is placed beneath the muscle. Depending upon the implant style, most surgical approaches can be used for sub-muscular placement.
This implant position is particularly good for women with thin breast tissue and skin damage such as stretch marks from pregnancy. The extra thickness that the muscle layer provides helps to achieve a smooth, natural shape.
Sometimes, if the pectoralis muscle is strong, there is some distortion of the breast when a patient flexes her chest muscles. The tension of the muscle against the implant is not painful and it does not affect arm strength, but the appearance can be bothersome to some patients. If this is a concern, then changing the implant position to lie over the muscle is a consideration. This is not a common request, even among fitness enthusiasts, but it’s always good to know that there are other options to consider for the best possible outcome.
The newest approach to implant placement involves creating a space between the thin but strong connective tissue layer (fascia) that covers the front of the chest muscle but lies behind the breast tissue. Having the implant in this position gives a smoother contour, especially at the edges of the breast, but does not create muscle tension when flexing the chest muscles.
It is a more lengthy procedure, so the anesthetic time can be longer, but for thin, athletic women who like to do a lot of upper body resistance training, this can be a good choice. The incision location to create this implant location is placed just beneath the areola. Because of the requirements of the surgical dissection, an underarm incision cannot be used for sub-fascial implant placement.
Each implant location is a good one for the right patient. This decision is part of an individualized approach that I take with my patients during the consultation visit. We address all the pros and cons and establish the best choice of implant size, style and location to achieve the best possible outcome.