Above or below the muscle with breast implants: Which is best ?

Breast implants for mastectomy reconstruction and cosmetic augmentation can have a profound positive effect with happy patients.  The can also cause problems in a small subset of patients, which is a cause of great frustration to patients and their plastic surgeons.  The main problems that can occur that require implant revision or removals are shape changes, tightening of the skin and tissues around the implant (capsule contracture) and implant deflation or rupture.

Breast implants do NOT cause or increase risk of breast cancer, and some studies show a DECREASE in risk with implants and earlier detection when a breast lump or cancer develops.

One way surgeons in the the past have tried  prevent position or scar contracture problems was to place the implant below the pectoralis major muscle, in what surgeon call the “sub-pectoral” plane.  Plastic surgeons thought that the advantages were twofold:

A LAYER OF MUSCLE BETWEEN THE IMPLANT  AND BREAST TISSUE

 Because it was not known in the past what effect implants would have on breast tissue, surgeons thought it could be safer to have a muscle layer separating the breast from the implant. 

 STUDIES DEMONSTRATED A REDUCTION IS THICKENED SCAR CONTRACTION AROUND THE IMPLANT, CALLED CAPSULAR CONTRACTURE. 

Contractures are deforming and can be uncomfortable and could happen in over 1 in 5 patients in older studies. 

All this information made sense,  and for years I placed implants below the muscle. But this technique was not without a few problems.

The surgery is a bit more “destructive” to the patient, creating a space below the muscle and stretching the muscle outward .  This could result in some more post operative soreness. When patients flex their chest muscles, the implants could move and cause a deformity of the shape. 

The pectoralis muscle runs across the mid chest , only a bit below the nipple. Over time there can be a ridge deformity where the implant is nicely covered on top by the muscle and below the skin and tissues are thinner. 

Breast implants for mastectomy reconstruction and cosmetic augmentation can have a profound positive effect with happy patients.  The can also cause problems in a small subset of patients, which is a cause of great frustration to patients and their plastic surgeons.  The main problems that can occur that require implant revision or removals are shape changes, tightening of the skin and tissues around the implant (capsule contracture) and implant deflation or rupture.

Breast implants do NOT cause or increase risk of breast cancer, and some studies show a DECREASE in risk with implants and earlier detection when a breast lump or cancer develops.

One way surgeons in the the past have tried  prevent position or scar contracture problems was to place the implant below the pectoralis major muscle, in what surgeon call the “sub-pectoral” plane.  Plastic surgeons thought that the advantages were twofold:

A LAYER OF MUSCLE BETWEEN THE IMPLANT  AND BREAST TISSUE

 Because it was not known in the past what effect implants would have on breast tissue, surgeons thought it could be safer to have a muscle layer separating the breast from the implant. 

 STUDIES DEMONSTRATED A REDUCTION IS THICKENED SCAR CONTRACTION AROUND THE IMPLANT, CALLED CAPSULAR CONTRACTURE. 

Contractures are deforming and can be uncomfortable and could happen in over 1 in 5 patients in older studies. 

All this information made sense,  and for years I placed implants below the muscle. But this technique was not without a few problems.

The surgery is a bit more “destructive” to the patient, creating a space below the muscle and stretching the muscle outward .  This could result in some more post operative soreness. When patients flex their chest muscles, the implants could move and cause a deformity of the shape. 

The pectoralis muscle runs across the mid chest , only a bit below the nipple. Over time there can be a ridge deformity where the implant is nicely covered on top by the muscle and below the skin and tissues are thinner. 

Breast implants for mastectomy reconstruction and cosmetic augmentation can have a profound positive effect with happy patients.  The can also cause problems in a small subset of patients, which is a cause of great frustration to patients and their plastic surgeons.  The main problems that can occur that require implant revision or removals are shape changes, tightening of the skin and tissues around the implant (capsule contracture) and implant deflation or rupture.

Breast implants do NOT cause or increase risk of breast cancer, and some studies show a DECREASE in risk with implants and earlier detection when a breast lump or cancer develops.

One way surgeons in the the past have tried  prevent position or scar contracture problems was to place the implant below the pectoralis major muscle, in what surgeon call the “sub-pectoral” plane.  Plastic surgeons thought that the advantages were twofold:

A LAYER OF MUSCLE BETWEEN THE IMPLANT  AND BREAST TISSUE

 Because it was not known in the past what effect implants would have on breast tissue, surgeons thought it could be safer to have a muscle layer separating the breast from the implant. 

 STUDIES DEMONSTRATED A REDUCTION IS THICKENED SCAR CONTRACTION AROUND THE IMPLANT, CALLED CAPSULAR CONTRACTURE. 

Contractures are deforming and can be uncomfortable and could happen in over 1 in 5 patients in older studies. 

All this information made sense,  and for years I placed implants below the muscle. But this technique was not without a few problems.

The surgery is a bit more “destructive” to the patient, creating a space below the muscle and stretching the muscle outward .  This could result in some more post operative soreness. When patients flex their chest muscles, the implants could move and cause a deformity of the shape. 

The pectoralis muscle runs across the mid chest , only a bit below the nipple. Over time there can be a ridge deformity where the implant is nicely covered on top by the muscle and below the skin and tissues are thinner. 

My thinking about implants going above the muscle again changed over the past 15 years as some leading plastic surgery researchers proposed new ways of thinking about implant healing and problem prevention.  Dr. William Adams and Tebbets in Texas helped define ways of limiting the problem of capsule contracture by proposing that it could be caused by microscopic inflammation, possibly from  bacteria.  With new ways of placing implants without ever touching the skin using funnels, inframammary incisions, and decontaminating the implant pocket with antimicrobial solutions, the rate of contracture in my practice fell to under 1 %.   I have always been meticulous about stopping bleeding in surgery, and placing the implant in a  clean, dry field further prevents contracture and scarring.   Dr. Frank Lista in Toronto also shaped my thinking by presenting data on implant placement below the muscle fascia layer, but above the muscle. This creates a barrier to the breast tissue which might have natural bacteria in the ducts, but keeps the muscle in place.  Using this subfascial technique over the [past years, along with the multitude of capsule contracture preventing maneuvers, I have not had a single case of capsule contracture in a cosmetic patient ( though a few in reconstruction after mastectomy).  I have also not had a single patient develop breast cancer, a recurrence or BIA- ALCL ( a rare lymphoma seen in some breast implant patients).  

The prepectoral placement of implants in my cosmetic surgery practice was a game changer especially with my use of saline implants as a preferred method. Switching to prepectoral placement for mastectomy reconstruction was a more gradual transition, but had an even more significant benefit for my patients. 

With prepectoral breast implants, my patients have more comfort  and outstanding cosmetic results.  To learn more about the best in breast surgery, including saline implants, breast reconstruction revision options, and maximizing safety and beauty in plastic surgery, you can reach out to our practice for an in person or video visit.

www.drsuzman.com

Instagram @suzmanplasticsurgery

 Dr. Michael S. Suzman is a member of The American Society of Plastic Surgeons, The Aesthetic Society and a Fellow of the American College of Surgeons. 

He has practiced plastic surgery in NYC, Westchester and Greenwich since graduating form Cornell Medical College in the Upper East Side of Manhattan in 1996,

He operates at Rye Ambulatory Surgery Center in Westchester County NY,  Greenwich Hospital in CT.