Breast Implant Position Part IV

Part IV: Over and Under the Muscle!, a Blog by Dr. Loftus

Obviously, breast augmentation is not just about size. When you first make the decision to have an augmentation you may be primarily motivated by an increase in size. However, shape is very important too. We want to give you the size you want, but we also want to give you a great shape. You may want a more teardrop shape or a more rounded shape with upper pole fullness. Either way, the techniques we use allow us to influence shape. As we discussed in "Over the Muscle," placing the implant under the breast allows the implant to fill out the breast and influence breast shape more than under the muscle. Unfortunately, it does not provide as much soft tissue coverage as placing the implant under the muscle, which most breast augmentation patients need. Further, placing the implant under the muscle can result in distortion of the implant and breast shape when the pectoral muscles contract. Finally, the implant may sit too high.

How can you get some benefits of both? Dual plane placement may be the answer for you. Dual plane positioning is a modification of the partial submuscular technique. The technique involves disconnecting the part of the pectoral muscle that sits above the inframammary fold which allows the implant to sit properly at the fold for a more natural shape (like many partial submuscular techniques). The modification involves separating some of the lower breast tissue from the muscle. The amount of breast tissue that is released from the muscle depends on your breast shape and degree of sag. This separation of the lower breast tissue from the muscle essentially creates a subglandular pocket in that area. This puts breast tissue in the lower half of the breast in direct contact with the implant. To clarify further, the upper part of the implant is under the muscle and the lower part of the implant is under the gland. The result is less muscular compression of the implant. Now the implant can have more of an effect on improving projection in the lower portion of the breast. The reduced implant compression also helps create a more natural shape in the upper half of the breast. This technique can be useful for improving shape in women with mild ptosis(sagging) because the implant can better fill out the lower half of the breast. It is important to note this is still not a substitute for a lift if you need one.

In this technique, the muscle coverage over the top of the implant increases soft tissue thickness in that area, making the implant less visible and less palpable. This makes it a lot less likely that you will have visible rippling in the area of your breasts that may be exposed in a low cut dress or bathing suit. You may still see rippling in the area of implant not covered by muscle—most commonly the lower, outer quadrant of the breast (which is usually covered by clothing).

The muscular release leads to less distortion of the breast with muscular contraction in addition to the improvements in shape. Fortunately, releasing part of the pectoral muscle does not cause problems for most people. The muscular attachments at your breast bone are left intact in a partial submuscular and a dual plane augmentation so the muscle is still functional. You can still work out after you recover from surgery. You can do all the same activities and sports with pectoral function intact. The one exception is competitive body building. Moderate weight lifting for fitness is okay. Competitive bodybuilders should probably avoid having an implant partially or completely under the muscle and opt for silicone implants over the muscle for the best result, considering their particular circumstances.

The benefit of decreased capsular contracture gained by placement under the muscle seems to be maintained with dual plane placement. The dual plane position thus has the benefits of enhanced soft tissue coverage and improved shape control. Although less painful than complete submuscular coverage it is more painful than subglandular positioning. Among the problems with a dual plane augmentation are that the "release" of the pectoralis muscle from the overlying breast tissue allows the muscle to retract upward. This translates into less coverage of the implant and a less natural look and feel for many women. Also, the rate of capsular contracture may be higher.

Overall, most women seem to get the most benefits from subpectoral placement of implants for the best cosmetic result and the lowest risk of complications.