Breast Enlargement Surgery – under the muscle or over
Here, Aurora Clinics Plastic Surgeon Adrian Richards shares his thoughts on the placement of breast implants.
I find the decision as to whether to place implants above or below the muscle a difficult one and each surgeon that I talked to has a different percentage of patients in which they place the implant under or over the muscle.
I never use a total sub-muscular coverage and neither do any of the surgeons I know. Total sub-muscular coverage involves coverage of the implant by serratus-anterior in the lower portion of the breast and pectoralis in the upper portion.
I think most surgeons nowadays use a dual-plane position with the pectoralis major anterior to the implant in the upper part and serratus behind the implant in the lower part.
The problem with dual-plane position is unless the muscle is adequately corrected, a double bubble can occur and in general, if the upper breast pinch width is over 2 centimetres I recommend sub-glandular placement, if it is less than 2 centimetres, dual-plane augmentation.
However, beware of the patient with the short distance between the nipple and the inframammary fold. In most cases this will be between 7 and 8 centimetres after surgery. If post-surgery this is less than that you will need to lower the fold on the affected side and my colleague Mark Tittos recommends the use of a spirit level to make sure your incisions are absolutely at the same level.
The problem with high inframammary fold in lowering the implant is that in dual-plane position the implant does not stretch this lowest skin adequately as any sub-glandular position.
Therefore I would recommend that it is possible to perform a sub-glandular implant. In patients with high inframammary folds and slightly tubular breasts this is the best way to go.
If however they have very little breast tissue with a pinch width of less than 2 centimetres the only option is to perform a dual-plane breast augmentation but it is essential to adequately release the pectoralis muscle so that its lowest part lies above the highest point of the breast implant. This will ensure that the pressure from the muscle produce the implant downwards rather than upwards.
Using this technique will reduce the risk of double bubble phenomenon.