In a previous post, one of the many breast implant options was discussed. Perhaps you have decided between saline and silicone implants. However, if you have had a chance to research the topic of breast augmentation, then you may already know that this is only the first of many decisions before proceeding with surgery. In this installment of our breast augmentation discussion, we will examine another decision, the location of the implant. Breast implants can primarily be placed above the chest muscles (subglandular) or below the chest muscles (submuscular or subpectoral) and each location has certain advantages and disadvantages.
Subglandular:
With subglandular placement, the implant is positioned immediately behind the breast gland or tissue but in front of the pectoralis major muscle and its fascia. This is a reasonable position for patients that have a fair amount of breast tissue. The greatest benefit with this technique is that patients generally have less pain and a slightly shorter recovery period. In addition, if a woman is physically active, this position is not associated with any significant breast distortion with the muscle contraction. However, one of the downsides of this location is the increased visibility of the implant giving the patient a more augmented appearance. With less tissue covering the implant, the edges may become more apparent resulting in a rounder, "fake" look to the breasts. Other downsides include greater interference with mammography and breast cancer detection and a possible increased risk of capsular contracture. Capsular contracture is the formation of firm scar tissue around the implant that may result in changes in the shape of the breast and occasionally pain. This is also the most common complication of breast augmentation surgery.
Subfascial:
Though this location is not one of the above mentioned positions for an implant, it is a position that, in theory, has some of the benefits of each of the more common positions - subglandular and submuscular. The pectoral fascia is a sheet of connective tissue that separates muscles from each other and the surrounding tissue. Theoretically, an implant can be placed beneath the fascial layer of the pectoralis muscle thus providing more coverage for an implant and making it less visible than with the subglandular plane. Unfortunately, the pectoralis fascia is extremely thin and may be less than 1/2 of a millimeter in thickness. Therefore, the long-term benefit from such a thin layer of tissue remains to be seen and further study needs to be conducted.
Subpectoral:
This location usually means partial muscle coverage of the implant by the pectoralis major muscle. Due to the anatomy of the muscle, the upper portion of the breast implant is covered by the muscle while the lower portion remains subglandular. This site is generally better at disguising the presence of an implant and thus gives a more natural breast contour as the muscle softens the transition between the breast and the implant. This position is also associated with a lower rate of capsular contracture and offers less interference with mammograms. The downside of this position is that it is more prone to contour deformities and generally requires a slightly longer recovery period. A variation of the subpectoral site is the dual plane position in which the implant sits both behind the pectoralis muscle and behind the breast gland. This location may decrease the risk of a contour deformity with certain breast types while retaining the advantages of the subpectoral site.
Complete Submuscular:
Complete coverage of the implant was used in the past to reduce the risk of capsular contracture and implant visibility. This technique involves not only using the pectoralis muscle to cover the implant, but also surrounding muscle groups such as the serratus and rectus muscles. This procedure is associated with the highest risk of superior implant malposition and contour deformities and has a very lengthy recovery period. The lower portion of the breast also tends to have poor projection and definition due to the muscle's inability to fully expand. Today, this location is rarely used for primary breast augmentation, but still may be useful in the breast reconstruction patient.
Though each of these factors should be considered, none is more important than any other when trying to decide. Every woman's breasts are different and every woman deserves a customized approach. Ultimately, choosing the appropriate implant location is a decision best made between you and your surgeon, based on the advantages and disadvantages of each approach, relevant to your personal anatomy.
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