Position of the Implants During Breast Augmentation
A frequently discussed aspect of breast augmentation over the years has been the question of the position of the implants. The correct positioning of the implant is of great importance for the long-term success and a lasting aesthetic appearance of the breast after breast augmentation. In principle, the inserted silicone implants can be placed on different levels of the breast. A distinction is made between submuscular position (below the muscle) and subglandular position (above the muscle), with regard to the large pectoral muscle.
When positioning the implant under the muscle, a distinction is made between complete placement of the implant under the pectoral muscle on the one hand and partial coverage by the pectoral muscle on the other (‘dual-plane’ technique). In this process, part of the muscle is detached and mobilized, whereby the lower implant pole is covered exclusively by mammary gland tissue. There is no resultant loss of muscle function. Especially in the case of very large implants used for breast augmentation, it can be useful to sink at least part of the implant under the pectoral muscle. In this way, the advantages of the submuscular position (i.e. under the muscle) are used for at least half of the implant, so that breast augmentation can be performed with a reduction in the risk of developing capsular fibrosis.
Breast augmentations with implants under the muscle offer a number of advantages, which we would like to make available to patients. The most important aspect here is good blood circulation under the muscle, which protects the inserted silicone implant and has demonstrably lower capsule fibrosis rates than with the position above the muscle. The so-called capsule fibrosis is a hardened connective tissue capsule around the implant, which occasionally occurs after breast augmentation. Since this phenomenon causes pain as well as breast deformations, the therapy is usually carried out by a renewed operation in which the implant is replaced. This is prevented by the position of the implant under the muscle. Furthermore, the muscular cover prevents the implant from deforming in the sense of wrinkles or furrows (also called ‘rippling’) visible from the outside during movements of the upper extremities. By covering the upper breast pole, a more natural breast shape can usually be achieved. In addition, the implant is felt less after breast augmentation, so that the palpation produces a softer and more natural breast than if the implant were placed directly under the skin. However, breast augmentation with implants placed under the muscle also has some disadvantages. Due to the muscle’s relative strength, the maximum projection of the implant is often limited. Furthermore, with this positioning it is possible that a visible (temporary) displacement or deformation of the implant may occur during physical activity, especially in the area of the upper extremities. Although very few patients complain about such difficulties after breast augmentation, it’s necessary to discuss this with patients, especially active ones.
Breast augmentations with implants placed over the pectoral muscle offer a significantly larger projection per implant volume and thus a more attractive breast shape for patients who wish to have large implants. Women with weak connective tissue and a sufficient surrounding soft tissue mantle, which provides an optimal embedding for the implant, can benefit cosmetically. Some surgeons prefer this implant position for breast augmentation, especially for athletic women or bodybuilders who want to avoid implant deformations due to muscle contraction. The disadvantage of implants for breast augmentation located above the muscle is that deformations tend to be more visible from the outside. The wrinkles and furrows already mentioned cannot be concealed by muscle tissue. However, if sufficiently covered with soft tissue, a change in the shape of the implant can also be sufficiently concealed. The same applies to the natural feeling of the breast after breast augmentation. Implants located above the muscle are usually felt more depending on the surrounding soft tissue coverage.
We carry out a special maneuver in order to utilise the advantages of a good blood circulation situation and to keep the capsule fibrosis rates low for breast augmentation with implants located above the muscle. The muscle skin (muscle fascia) of the large pectoral muscle is also lifted on the surface to the skin. This allows the breast augmentation to be performed over the muscle – i.e. subglandular. However, the silicone implant is covered with the muscle skin (subfascial layer). This procedure also leads to a significant reduction in the number of capsules formed.
Breast Augmentation with Implants: Which skin incision is appropriate for me?
As with the choice of implants, the plastic surgeon also has various options, i.e. the skin incision for breast augmentation. As a matter of principle, aesthetic plastic surgery always aims to keep the incision small and inconspicuous in order to make the result of breast augmentation as natural as possible. This makes it possible to make the incision directly through the nipple and areola, to avoid scarring. Similar to the incision made at the border between the areola and the skin, the main problem here is that large implants (anything over 300 ml) are difficult to insert through the resulting small opening. In addition, the gland is manipulated and cut, which can have an effect on the ability to breastfeed after breast augmentation. Alternatively, access via the navel is available, which is, however, disadvantageous in that only saline implants can be inserted through it. This is because the desired volume for breast augmentation can only be filled from the outside with a syringe after the empty saline implant has been inserted. Silicone implants are too large to be inserted via the navel for breast augmentation. Incisions through the underbust crease or the armpits are alternatives for inserting silicone implants. While the armpit offers more risk of injury to nerves and vessels, access in the underbust crease provides better visibility of the surgical area. In this way, surgery can be performed safely and without scarring.
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