Advanced Art of Cosmetic Surgery     Thomas M. DeWire, Sr., MD, FACS    Specializing in Cosmetic Plastic Surgery     Richmond, Virginia, USA



       Anatomical explanations of Breast Implant Placement options and recommendations         Advanced Art of Cosmetic Surgery     Thomas M. DeWire, Sr., MD, FACS    Specializing in Cosmetic Plastic Surgery     Richmond, Virginia, USA

Breast Implant Procedures

Anatomy of Chest Wall and Breast Implant Placement Over or Under the Muscle



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Chest Wall Anatomy and the relationship to Breast Implant Placement:  


The final outcome and shape of  breasts after implant enlargement or Augmentation Mammaplasty   is in large  part  determined  by the relationship of the implants  to the pectoralis muscles of the chest wall.  Implants can either be placed above (OVER) the  pectoral  muscles, or beneath (UNDER) the muscles.  Furthermore, the route of placement of  implants  under  the muscle also determines  whether the implant is totally  covered or  only partially covered by muscle when  it is  placed in the  sub-pectoral  plane.  A number of consequences may result according to the position and route of placement of implants, and some of the potential complication risks of Breast Augmentation can thus be altered by adhering to certain  principles of  implant placement  when  feasible.  These  include  limiting  risk  of capsule contracture, limiting  the  "round" look  of implants, preventing visible rippling   or wrinkling of the implants, preventing "bottoming-out" of the implants, and most importantly,    limiting compromise  of Mammography  after augmentation.  An example of "bottoming-out" is seen by following this LINK.


Breast Implants Over the Muscle:

The photos at left show implant placement over the muscle in the sub-glandular position, completely in contact with the breast tissue.  The result of implants over the muscle provides a round augmented look in many patients, but many women prefer the round and somewhat less natural look.  In the "over" approach the implants are insideá the breast.  Advantages are ease of the surgery, which can be accomplished by almost any surgeon, avoidance of mastopexyá in mild ptosis (although it usually makes the ptosis worse later), less post-op discomfort, since only skin and fat are cut.  This approach allows insertion of oversize implants, which is again what some women want. Disadvantagesá are marked interference with mammograms (about 40% obstruction - see reference below), clear visibility and feel of implant edges, visible and palpable rippling of the skin over the implants, especially with any textured implants, higher rate of capsule contracture, high rate of later implant downward migration or "bottoming-out", and difficulty correcting later posts problems when they occur.  For the above reasons I seldom recommend implants over the muscle anymore.

Breast Implants Partially Under the Muscle:

Photos at left show partial submuscular implant coverage with implants placed under the muscle via either an areola (nipple) incision or an inframammary crease incision, thus disrupting the muscle support fascia at the lower pole of the implant to allow it to enter the space under the muscle. With this approach the implants are mostly behind the breast. This approach has the Advantages of mostly separating the implants from the muscle, facilitating unobstructed mammography, a more natural look with a soft transition from the flat of the upper chest wall to the round shape of the implant, much less visibility and feel of the implant edges, usually no rippling (except textured implants), and low risk of capsule contracture, as long as the implants have not been contaminated by ductal germs while being passed through the breast tissues.  Disadvantages include a bit more discomfort early post-op, technique a bitáámore difficult than over the muscle, and the loss of the lower pole support fascia which leave the implants supported by the same weak skin tissues as implants over the muscle, leading to later downward bottoming-out of the implants in a few patients as is frequently seen in implants over the muscle.

Breast Implants Completely Under the Muscle:

Complete implant muscle coverage is shown at left with intact muscle fascia supporting the lower pole of the implant.  This support fascia is the extension of the muscle envelope from the pectoralis musclesá to the abdominal rectus muscles, and the finger shaped serratus anterior muscles to the sides, and is a stout collagen sheet which stretches slowly after implant placement, but provides reliable long-term internal bra-like support to prevent "bottoming-out".  With this approach the implants are totally behindá the breast.  Complete muscle coverage of the implant, without cutting through the muscles, can onlyábe achievedáby trans-axillary approach, entering the space under the muscle where it lies closest to the skin in the anterior axillary fold.  The Advantages of this approach are ease of placement, natural breast shape no implant visibility, no ripplingá of the implant surface (except textured implants in thin women), lower capsule contractureá risk, since the breasts are completely separated from the implant, and no ducts with germs are damaged while placing the implants, low mammography interference, good internal support, and no scars on the breast. Disadvantagesáare the difficulty mastering the procedure, thus it is not available from all surgeons, muscle discomfort post-op, and implants which tend early to be a bit full superiorly, until the support fascia stretches.  Thisááis my preferred technique for the majority of patients.

Comparison of various implant positions:


Implant Location
Over Muscle Partial Under Muscle Complete Under Muscle
Mammography Marked interference even with Eklund distraction technique Minimal interference with Eklund distraction technique Minimal interference with Eklund distraction technique 
Capsule Contracture Highest risk Lower  risk Lowest  risk
Rippling Highest risk especially with any textured implants Lowest risk even with  textured implants Lowest risk even with  textured implants
    Natural Appearance     +/- Likely  Likely
Implant Bottoming out Frequently seen - leads to inframammary scars riding up onto the breast Frequently seen - leads to inframammary scars riding up onto the breast

Rarely seen

Use in presence of borderline sag May correct sag in short term, but usually requires later ptosis repair because breast support ligaments (of Cooper) are cut May correct borderline sag  but may require immediate or later mastopexy May correct borderline sag  by pectoral sweep maneuver, but may require immediate or later mastopexy
Late Sag requiring repair Frequently seen especially  if over muscle was done to try to "fix" sag Less frequent, but may be needed after pregnancy Less frequent, but may be needed after pregnancy



Links to reference articles:


Eklund Displacement Mammography:

TITLE: Improved imaging of the augmented breast.

Article Link

AUTHORS: Eklund GW, et al.
SOURCE: AJR Am J Roentgenol. 1988 Sep;151(3):469-73.

Over muscle versus under muscle  implant interference with mammography:

TITLE: Mammographic measurements before and after augmentation mammaplasty

Article Link

AUTHORS: Silverstein MJ, et al.
SOURCE: Plastic and Reconstructive Surg. 1990 Dec;86(6):1126-30.

Factors affecting mammography after implants

TITLE: Factors affecting mammographic visualization of the breast after augmentation mammaplasty

Article Link

AUTHORS: Handel N, et al.
SOURCE: JAMA. 1992 Oct 14;268(14):1913-7.


Related  Breast Augmentation Links:   To Other photo Illustrated Procedures:

Important  Information  About  Implant  Breast  Enlargement

Trans-Axillary Breast Augmentation
Trans-Axillary Breast Incisions Scars
Breast Augmentation Shape Evolution
Breast Augmentation Shape Determination
Cleavage Determinants
Post-Op Implant Massage Technique
Implants Over versus Under the Muscle
Special Considerations in Augmentation
Breast Surgery in African American Women
Breast Augmentation FAQs
Breast Augmentation with Mastopexy or Breast Lift
Revision Surgery for Augmentation Problems
Important Information about Silicone Breast Implant Use
Nipple Reduction/Shaping
Mastopexy or Breast Lift

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Thomas M. DeWire, Sr., MD, FACS
Advanced Art of Cosmetic Surgery
3974 Springfield Road
Glen Allen, VA 23060
Richmond, Virginia, USA
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ęCopyright 1997-2013  Advanced Art of Cosmetic Surgery:  Thomas M. DeWire, Sr, MD, FACS   Revised:   September 09, 2014 06:03 PM