What are the differences between placing the implant under the muscle or under the gland?
Placement of breast implants
(Discussion to topic Breast augmentation - Breast implants)
There is no difference. Where the choice of surgeons implant to be placed depends on the thickness of tissue that covers the skin imlant and quality and degree of ptosis.
It depends on preoperative tissues evaluation
Implants placed under the muscle have a somewhat smaller degree of capsular contracture, but postoperative pain is also greater, and patients present what is called a "dynamic breast", as it moves along with movements of the arms. The only absolute reason to place them under the muscle is in very thin patients that would show the border of the implant if it is placed directly under the gland, because they lack of sufficient tissue to camouflage the presence of the implant. It is also recommended in patients operated for capsular contracture in a subglandular position, to reduce the risk of recurrence.
Over the muscle technique implies 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, but only a few 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), less post-op discomfort, since only skin and fat are cut. This approach allows insertion of oversize implants, which is again what some women want. Disadvantages are marked interference with mammograms , clear visibility and feel of implant edges, visible and palpable rippling of the skin over the implants, especially with any textured implants, higher rate of capsule contracture, high rate of later implant downward migration or "bottoming-out", and difficulty correcting later post problems when they occur. For the above reasons we do not recommend implants over the muscle anymore.
Under the muscle-implants are placed under the pectoral muscle via an inframammary crease incision, under the muscle fascia at the lower pole of the implant to allow it to enter the space under the muscle. With this approach the implants are mostly behind the breast tissue under the muscle layer. This approach has the advantages of mostly separating the implants from the gland thus facilitating unobstructed mammography, a more natural look with a soft transition from the flat of the upper chest wall to the round shape of the implant, much less visibility and feel of the implant edges, usually no rippling , and low risk of capsule contracture.Disadvantages include a bit more discomfort early post-op, technique a bit more difficult than over the muscle, and the loss of the lower pole support fascia which can be prevented by strategic suture placement to recreate the submammary crease thereby diminishing this risk. This technique being more favourable on the long run, we preffer this technique to the over the muscle implant placement.
Md PhD Tiberiu Bratu
Professor of Plastic and Esthetic Surgery
Brol Medical Center
Timisoara, str F Zoltan nr.6
Tel: 40256221009 / 40722356238
Better coverage under the muscle with less upor pole visible edges.
If implant is inserted behind the pectoral muscle, the muscle is cut, and if it is inserted behind the breast, a pocket is created behind the breast for insertion of implant.
When the implant is placed under the gland the appearance is more attractive with better cleavage and less post operative pain. However in thin individuals implant visibility seperate from breast tissue is a possibility. Some studies have revealed that implant placed under the gland has more chance of infection and capsular contracture. When placed under the muscle the appearance is more natural with some studies suporting the facts of low infection rate and capsular contracture. In women involved in sporting activity using the pectoral muscles there could be some discomfort.
Submuscular placement of a breast implant involves the creation of a surgical pocket under the pectoralis major muscle to provide greater soft tissue coverage over the implant. Subglandular implant placement results from placement of the implant above the muscle but under the breast itself. Submuscular implant placement is much more painful but can provide increased coverage of an implant when necessary.
The muscle over the implant assures an extra coverage over the implant when that is considered necessary, but the recovery is a little bit more painful and slower, but that should not be an issue when considering the implant placement, most important are long term results.
Placing the implant under the muscle may decrease the possibility of capsule formation but this is not a guarantee.Also in this case the implants are more distant from the milk ducts. ALSO the decision depends on the breast shape if there is a ptosis,the breast is too low in relation to the mammary fold ,positionng the implant under the muscle may worsen the problem.The surgeon should evaluate and explain his choice
Both saline implants and silicone implants can be placed through three types of breast augmentation incision locations:
Infra-mammary (under the fold of the breast)
Peri-areolar (near the nipple area)
Axillary (underarm area)
Although most smaller silicone implants (less than 275-300 cc) that can be placed through an axillary or peri-areolar incision, larger silicone implants require an infra-mammary incision. Both saline and silicone implants can either be placed under or over the chest muscles (pectoralis muscle) depending on your anatomy and the 'look' that you are interested in achieving.Most patients have the implant placed beneath the pectoralis muscles, and the implants appear to last longer and perform better in this submuscular position
Behind the gland in some cases it is more natural, but if you're too thin should behind the muscle. Regards
Breast Implants must have a fair tissue covering to prevent showing and beeing palpable and visible, so when present tissue as skin envelope and gland are not enough represented to give a good covering to implants, is recommended to place underneath the pectoralis muscle.
Alberto Di Giuseppe, Plastic surgeon @The Private Clinic