Breast implants: “Over or Under?” What about both?

Simply put, if you are considering breast augmentation, it is likely that you want more beautiful breasts.  My goal is to achieve the most natural and beautiful breast augmentations that I can.How I achieve that depends upon my skill, experience and judgment.

One of themost important considerations when planning a breast augmentation operation is how I willplace the implants with respect to the “muscle,” the pectoralis major muscle on your chest.  Said another way, in what plane will they be located?

  • Breast implants placed below the muscle are said to be in the submuscular, or subpectoral, plane or position
  • Implants placed above the muscle are said to be subglandular, or in the plane under the breast gland and over the muscle.

I find that most people are rarely fully informed about this important subject, so I would like to share with you the way I approach this issue with my patients. There are many reasons why a patient and her surgeon may pick one or the other location for her breast implants.  Typically I advise my patients of the pros and cons of each. Then I give them the final decision based upon their goals and how they feel about the pros and cons we discuss.

The breast is not naturally a submuscular organ.  Believe it or not, it is more like a physiologically modified collection of sweat glands that develops above the muscles.  As such, it has more to do with the skin than it does with the muscle.  Thus, technically speaking, placing breast implants under the pectoralis muscle is not an anatomically accurate way to recreate a breast.

Most patients have been told that “under the muscle is always better.” This is the position used most frequently by surgeons so that is the conventional wisdom.  The vast majority of breast implants today are placed in the submuscular plane.Over the years we have done this for a variety of reasons. The main advantages of placing breast implants under the muscle are:

1)      A more natural appearanceof the upper part of the breast is typically obtained as the muscle adds some additional tissue thickness to cover the implant and soften and camouflage its contour. This is why it works despite the anatomical inaccuracy of it all.

2)      The incidence of capsule contracture is less when implants are placed below the muscle for reasons that we don’t fully understand.

3)      Generally mammography is easierwhen there is muscle between the implant and the breast tissue itself.

The main disadvantages of placing implants below the muscle are:

1)      Contour is not always natural on the bottom of the breast, and the breasts can move abnormally with muscle contractionunless the muscle is released properly.

2)      The breast tissue itself cannot always expand to follow the contour of the implant, and this can give rise to later problems such as “double bubble” and “Snoopy breast” deformities

3)      Recovery time is sometimes a bit longer and there is a bit more soreness in the chest because the divided muscle has to heal.

Wouldn’t it be great if we could have the best of both worlds?  Eliminate the “or” in favor of the “and!”

This way of thinking gave rise to the Dual Plane Mammaplasty. This approach to breast augmentation uses both the submuscular and the subglandular planes. It takes the best advantage of both approaches.  The dual plane technique was first conceived to treat women with some laxity in their breast tissue resulting from aging or breast-feeding. This avoided the need for a lift in many instances.  Basically, in the dual plane approach:

  • I raise the muscle and position the implant beneath it, just as in a submuscular augmentation. This allows the top portion of the breast implant to rest beneath the muscle, making it a true submuscular implant with all of the advantages that provides.
  • On the lower portion of the breast, the part where we really want the breast tissue to “drape around,” or adopt the contour of the implant, I createa subglandular space allowing the bottom of the implant to fill the subglandular plane. The breast then becomes full and round without the tendency to form double bubbles or “Snoopy breast.”

I now use the Dual Plane Mammaplasty technique on all of my breast augmentation procedures because I think it really does produce the most natural and beautifully shaped breasts.