Surgical Options:
Over/Under Muscle, Implant Shape and Size, Incision Location
“No set of surgical options or implant options is perfect for every patient— every option has trade-offs.”
Many different surgical options exist in breast augmentation. To be able to offer you options, a surgeon must be familiar with different approaches and implants and have the experience and skill to apply those options confidently.
No specific set of surgical options is best for every patient.
If you are offered only one set of options, that may be the only options a surgeon can offer—consult other surgeons.
Every patient tends to think that the options she chose are also the best options for someone else. that isn’t true because no two women are exactly alike. Your tissues are definitely different!
No surgical option is perfect.
No surgical option is without trade-offs.
The question is whether you know the relative benefits and trade-offs and pick the options that best maximize the benefits and minimize the trade-offs.
If you and your surgeon don’t discuss your tissues and how your tissues influence the best choice of implant for you, you will need to blame something or someone for the consequences.
You will probably blame the implant or the surgeon, when it’s really you who’s largely responsible.
Location of the Pocket for the Implant
Over or Under Muscle?
The most important priority in selecting a pocket for the implant is to assure optimal tissue coverage over your implant for your entire lifetime. Optimal tissue coverage means assuring that all portions and edges of your implant are covered by the most tissue available, given your body characteristics.
If your tissues are thin in the areas that cover your implant (and we will show you how to measure later), you may need to put the implant partially behind muscle, especially in the upper and middle areas of the breast, to assure adequate tissue cover over the implant. If you don’t, you run more risks of seeing the edges of your implant and seeing visible traction rippling later, both of which are usually uncorrectable. But there is much more to making the decision.
Breast implants in the past have been placed in one of two locations:
- Behind your breast tissue but in front of your pectoralis muscle— retromammary placement (Figure 6-1), or
- Partially behind your pectoralis muscle— partial retropectoral placement (Figure 6-2).
Now there is a new and frequently better option: dual plane1—behind muscle in the upper breast and behind breast tissue in the lower breast—the best of both worlds (1&2) above, while minimizing the trade-offs of each! (Figure 6-3)
When silicone-gel-filled implants were available and widely used in the United States, surgeons began placing implants partially behind the pectoralis muscle because silicone-gel implants had a lower risk of capsular contracture (excessive firmness) when they were placed partially behind the pectoralis. With today’s saline-filled implants, the risk of capsular contracture is about the same whether the implant is placed in front of the muscle or behind the muscle. So, what difference does it make, and how do you choose? The choice is based on the thickness of your tissues—how much thickness you have to cover your implants.
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References
1 Tebbetts, J. B. Dual plane (DP) breast augmentation: optimizing implant-soft tissue relationships in a wide range of breast types._ Plast. Reconstr. Surg._ 107: 1255, 2001
2 Tebbetts, J. B. Achieving a predictable 24-hour return to normal activities after breast augmentation, part I: Refining practices using motion and time study principles. Plast. Reconstr. Surg. 109: 273-290, 2002.
3 Tebbetts, J. B. Achieving a predictable 24-hour return to normal activities after breast augmentation part I: Refining practices using motion and time study principles. Plast. Reconstr. Surg. 109: 293-305, 2002.
4 Tebbetts, J. B. Patient acceptance of adequately filled breast implants. Plast. Reconstr. Surg. 196(1): 139-147, 2000.
5 Tebbetts, J. B. Achieving a zero percent reoperation rate at 3 years in a 50 consecutive case augmentation mammaplasty PMA study. Plast. Reconstr. Surg. 118(6): 1453-57, 2006.