Is it best to place breast implants underneath or on top of the muscle?

Dr. Ramsey J. Choucair answers frequently asked questions about plastic surgery and the placement of breast implants at www.DrCPlasticSurgery.com

Is it best to place breast implants underneath or on top of the muscle?

One of the most important decisions you need to make when you consider breast augmentation is where you're planning to put the implant - above the chest, or pectoralis muscle, or below it. There are many variables involved in this decision and unfortunately or fortunately, there is much information on the internet and from friends to cloud your thoughts. The most important thing is to remember that you usually have a choice, although in some cases, one method might be recommended over the other. Because there are so many issues involved, you should really consider consultation with your board-certified and experienced plastic surgeon to make this decision.

The implant being placed beneath the muscle is very common with saline implants.

Because of the dynamics of the implant, saline implants tend to wrinkle and ripple more often and more characteristically than silicone gel implants. Also remember that when we say that the implant is placed beneath or underneath the chest muscle, it's only partially under the muscle. The muscle typically covers only the top half of the implant. The chest muscle doesn't extend so far down that it covers the entire implant. Not a major distinction, but that's the reality.

Saline implants will wrinkle for instance, when placed on the chest despite being filled correctly. You don't typically see the wrinkling unless there's very little breast tissue covering the implant. This is one of the reasons you go under the muscle. The bottom half of the implant is usually not covered by muscle and it's not necessary because you don't usually see wrinkling or rippling in that location. You may, however, see the implant below the muscle if you're extremely thin. You may feel the implant in almost any patient who has a breast augmentation, but hopefully, you won't see it. In certain garments, where the medial or the inner aspect of the breast is exposed, you certainly don't want to see any wrinkling of the breast. Another reason to go under the muscle is that there can be a smoother transition from the chest wall to the implant. For all these considerations, saline implants almost universally go under the muscle.

With the silicone gel implant, there is not as much wrinkling and rippling to show. If you have adequate breast tissue, meaning more than maybe a small B, it is usually acceptable to place the implant on top of the muscle where it is covered only by your own breast tissue. It's also perfectly acceptable to put a silicone gel implant under the muscle.

So with silicone gel implants, you have a choice, because wrinkling is not as much of an issue. In our practice, we generally don't give patients that choice with saline implants, because any wrinkle or ripple that can be avoided must be avoided.

The other variable we'll discuss is the risk of something called "capsular contraction." Many of you may have heard of it. It's known in the lay press as hardening of the breast. The body tightens around the implant and makes the implant feel like it's hard. The implant itself is not hard, the body is just squeezing it. We'll talk about this again in our complications section, but it applies to the discussion of placing implants above and below the muscle as well.

You may see it on the internet that placing the implant below the muscle reduces the risk of contraction. Unfortunately, the literature is not clear.

You need a board-certified surgeon to sit and sift through these issues with you so you know the truth - it's very easy to pick up on a myth and carry it on as fact. Contraction is not a health issue, it's a completely cosmetic issue. And the reason to bring it up in this section is because many times it colors a patient's decision about where to put the implant.

We typically put gel implants above and below the muscle and have not seen a significant difference in contracture rates. And we don't think it's because we have magic hands, we believe it's because doing meticulous dissection with very little bleeding creates an even playing field and above and below the muscle can work for any patient. So therefore, you have a viable choice of placement options with gel implants.

The final word is that if you get a contracture, and the implant is above the muscle, our experience is that the contracture may not even need surgery. And many times contractures don't need surgery. If the implant is placed below the muscle and you get a contracture, it's typically more severe and typically leads to surgery, (because of cosmetic reasons, not health reasons), than if you had the implant on top of the muscle. Again, a long discussion of above and below the muscle, but all these things factor into that equation.

Видео Is it best to place breast implants underneath or on top of the muscle? канала Ramsey J. Choucair, MD