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| Important
Information |
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| Important
Info about Breast Augmentation |
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Anatomy of Chest Wall and Breast Implant Placement Over or Under the Muscle
The final outcome and shape of breasts after breast enlargement or augmentation mammaplasty
is in large part determined by the relationship
of the implants to the pectoralis muscles of the
chest wall. Implants can either be placed above
(OVER) the pectoral muscles, or beneath (UNDER)
the muscles. Furthermore, the route of breast implant placement under the muscle also determines whether
the implant is totally covered or only partially
covered by muscle when placed in the sub-pectoral plane. A number of consequences may result, depending on the position and route of placement of implants. By adhering to certain principles of implant placement, surgeons can prevent some of the potential complications of breast augmentation. These include limiting risk of capsule
contracture, limiting the "round" look
of implants, preventing visible rippling or wrinkling
of the implants, preventing "bottoming out"
of the implants, and increased longevity.
| Breast Implants Over the Muscle: |
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The photos above show breast implant placement over the muscle in the sub-glandular position, completely in contact with the breast tissue. The result of implants over the muscle provides a round, augmented look in many patients, though many women prefer the round and somewhat less natural look. In the "over" approach, the implants are inside the breast. Advantages are ease of the surgery, which can be accomplished by almost any surgeon, avoidance of mastopexy in mild ptosis (although it usually makes the ptosis worse later), and less post-op discomfort, since only skin and fat are cut. This approach allows insertion of oversize implants, which is what some women want. Disadvantages are marked interference with mammograms (about 40% obstruction - see reference below), clear visibility and feel of implant edges, visible and palpable rippling of the skin over the breast implants, especially with any textured implants, higher rate of capsule contracture, high rate of implant downward migration or "bottoming-out," and difficulty correcting later ptosis problems when they occur.
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| Breast Implants Partially Under
the Muscle: |
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Photos above show partial submuscular breast implant coverage with implants placed under the muscle via the areola (nipple) incision or an inframammary crease incision, thus disrupting the muscle support fascia at the lower pole of the implant and allowing it to enter the space under the muscle. With this approach, the implants are mostly behind the breast. This approach has the advantage of mostly separating the implants from the muscle, facilitating unobstructed mammography, a more natural look, less rippling (except textured implants), and low risk of capsule contracture. Disadvantages include greater discomfort, a higher difficulty in the technique, and the loss of the lower pole support fascia that leaves the implants supported by the same weak skin tissues as implants over the muscle, leading to later downward bottoming-out of the implants in a few patients, as is frequently seen in implants over the muscle.
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| Breast Implants Completely Under
the Muscle: |
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Complete implant muscle coverage is shown above with intact muscle fascia supporting the lower pole of the breast implant. This support fascia is the extension of the muscle envelope from the pectoralis muscles to the abdominal rectus muscles, and the finger shaped serratus anterior muscles to the sides. It is a stout collagen sheet which stretches slowly after implant placement, but provides reliable long-term internal bra-like support to prevent "bottoming-out". With this approach, the implants are totally behind the breast. Complete muscle coverage of the implant, without cutting through the muscles, can only be achieved by Trans-Axillary approach, entering the space under the muscle where it lies closest to the skin in the anterior axillary fold. The advantages of this approach are ease of placement, natural breast shape, no implant visibility, no rippling of the implant surface (except textured implants in thin women), lower capsule contracture risk, avoidance of duct damage, low mammography interference, good internal support, and no scars on the breast. The main disadvantages of this procedure are that it is difficult to master and there is likely to be post-op muscle discomfort. This is the favored breast augmentation technique for the majority of patients.
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Issue
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Implant
Location |
| Over
Muscle |
Partial
Under Muscle |
Complete
Under Muscle |
| Mammography |
Marked interference even with Eklund distraction
technique |
Minimal interference with Eklund distraction
technique |
Minimal interference with Eklund distraction
technique |
| Capsule
Contracture |
Highest risk |
Lower risk |
Lowest risk |
| Rippling |
Highest risk especially with any textured
implants |
Lowest risk even with textured implants |
Lowest risk even with textured implants |
Natural Appearance
(not desired
by all patients) |
+/- |
Likely |
Likely |
| Implant Bottoming
out |
Frequently seen - leads to inframammary
scars riding up onto the breast |
Frequently seen - leads to inframammary
scars riding up onto the breast |
Rarely seen
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| Use in presence
of borderline sag |
May correct sag in short term, but usually
requires later ptosis repair because breast
support ligaments (of Cooper) are cut |
May correct borderline sag but may require
immediate or later mastopexy |
May correct borderline sag by pectoral sweep
maneuver, but may require immediate or later
mastopexy |
| Late Sag requiring
repair |
Frequently seen especially if over muscle
was done to try to "fix" sag |
Less frequent, but may be needed after pregnancy |
Less frequent, but may be needed after pregnancy |
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