The top row shows a patient who underwent a subglandular augmentation (implants over the muscle) and several subsequent revisions by an outside surgeon prior to presenting to Ennis Plastic Surgery. The bottom row shows her after an endoscopic implant exchange from over the muscle to under the muscle. Note the tremendous improvement in the shape and contour of her breasts.
With the development of fiber optic technology the transaxillary approach, where the incision is made in the armpit, has become a technically more precise procedure. The endoscope (fiber optic camera) allows the implant pocket to be well defined and easily visualized, which ensures a more accurate placement of the breast implant during the breast augmentation procedure. The endoscopic technique also lends itself to placing the implant under the chest muscle, called a submuscular placement, instead of under the breast tissue, called a subglandular position.
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Advantages of Submuscular Implant Placement
There are several major advantages of the submuscular placement of the implant:
- Decreased rate of capsular contracture
- More tissue to cover the implant to prevent the implant from being easily seen or felt
- Better support of the implant by the muscle
- Better visualization of the breast tissue on mammograms.
In the top row, the patient originally underwent a subglandular breast augmentation (implants over the muscle) and one revision by an outside surgeon. She developed rippling related to the subglandular position and was unhappy with the lack of fullness. She then underwent an implant exchange to the submuscular position (implants under the muscle) by Dr. Ennis at Ennis Plastic Surgery. Note the improved overall appearance and shape of the breasts in the lower pictures when the implants are under the muscle.
Capsular contracture is the term used to describe the formation of scar tissue around the implant which, when thickened, can make the implant feel hard and round. Although the implant itself remains soft, the scar tissue "squeezes" the implant which makes the implant itself feel hard. When breast implants are placed under the muscle, the rate of capsular contracture is decreased in general from 15% to 3%. That's a significant difference.
Rippling occurs when the implant shell is easily felt and seen beneath the skin. With over the muscle placement, the possibility of this occurring is greater than when the breast implants are placed under the muscle. Large studies have shown that the chance of rippling is 3 times greater with over the muscle augmentation than with under the muscle augmentation.
Disadvantages of Submuscular Implant Placement
The disadvantage of the submuscular implant placement versus subglandular placement is that the postoperative recovery is lengthened and the patient may experience more postoperative pain. In addition, there may be more motion of the implant with forceful pectoral contracture such as doing exercises like bench presses and push-ups.
All things considered, the submuscular placement of an implant has a lower risk for the complications of capsular contracture and rippling.