Over or Under?

For many breast implant patients, the decisions of what size of implant to get and deciding between silicone and saline are the biggest considerations to make when discussing their augmentation surgeries with their plastic surgeons. While these decisions are important, they’re not the only decisions augmentation patients are going to have to make, according to Dr. Jack Peterson, M.D., a Topeka, Kansas, plastic surgeon.

“Another critical part of the process to talk about before going under the knife is deciding where the implant will go – over or under the chest muscle.” says Peterson.

To determine which kind of placement is best, patients should discuss with their plastic surgeons the look they are trying to achieve with their augmentation. Implants placed under the muscle are placed partially between the pectoralis muscle of the chest and the breast tissue. These under the muscle, or sub-muscular placements, typically provide a more natural final result. Another benefit of sub-muscular implants is less stretching of the skin as muscle supports the implant and keeps it from sagging.

Some plastic surgeons favor placing implants under the muscle because the risk of rippling is reduced. Rippling occurs when the folds or wrinkles of a breast implant can be seen through the skin. Rippling can develop in both silicone and saline implants and is caused by a number of factors, including oversized implants and thin or deficient breast tissue. Some physicians also believe that under the muscle placements may also allow the breast tissue to be seen more easily during a mammogram.

While under the muscle placement has its benefits, it also has its constraints. “Under the muscle placement limits the size of implant that can be used because of the limited space between the muscle and breast tissue,” says Peterson. Other potential negatives about under the muscle placement include longer recovery time and potentially more pain as this method of placement is a more invasive procedure.

Implants placed over the muscle, known as sub-glandular placements, also have their share of benefits and considerations patients should review when discussing implant options with their plastic surgeon. The surgery is less invasive and allows for a less painful, faster recovery. Larger implants can be used when over the muscle placement is selected, which is a very attractive factor for many patients.

Concerns to cover when selecting over the muscle placement is a less natural appearance may result and rippling may be visible. The implant may sag and stretch the skin without the support of the chest muscle. Over the muscle placements may obscure breast tissue during mammograms.

Patients may hopes of a particular placement in mind when they begin the consultation process for their implant surgery, but because of a variety of factors like implant size and available breast tissue, surgeons may have to take a different approach.

“The biggest factor in determining the implant placement is the amount of breast tissue the patient has available,” says Dr. Peterson. Patients that have thin breast tissue may benefit the most from below gland placement both by being covered by the gland, resulting in a more natural look. Alternatively, patients who have thick breast tissue will benefit from above gland placement, which allows support from the chest muscle. Peterson explains that these are not hard and fast rules, “Breast implant surgery is highly individualized. What works for one person may not work for the next.”

Because breast implant surgery is personalized to each patient, Dr. Peterson recommends patients research physicians to find an experienced plastic surgeon. “The consultation process is critical to inform and educate patients about options, risks, and outcomes.”