Under the muscle or Over the muscle?

Breast Implant Placement

Breast Augmentation surgery involves the creation of a pocket that allows for the placement of the breast implant above or below the chest muscle (pectoralis major). The pocket can be made in one of two places: under the breast itself (also known as sub-glandular or sub-mammary), or under both the breast and chest muscle (also known as sub-muscular or sub-pectoral). There are also three different methods through which a sub-muscular placement can be made.

1. Sub-Glandular (or Sub-Mammary) – when the breast implant is placed over the muscle and under the existing breast tissue.
2. Partial Sub-Muscular (or Sub-Pectoral) – when the breast implant is placed under the muscle, but the bottom part of the breast implant sits lower than the muscle (i.e., the lower half of the breast implant is not covered by the muscle).
3. Complete Sub-Muscular – when the whole breast implant is completely under the chest muscle.
4. Dual-Plane – when the breast implant is partially under the chest muscle, but a sub-glandular dissection is also performed to allow the repositioning of the breast tissue relative to the muscle. This is beneficial in women who are at risk of a double bubble (a visible distinction between the lower portion of the implant and the existing breast tissue) when implants are placed purely under the muscle.

Under the Muscle (Sub-Muscular)

A sub-muscular approach to Breast Augmentation can be performed through a complete sub-muscular or partial sub-muscular implant placement.

In the complete sub-muscular placement the implant is completely covered by the muscle and is unable to descend. This is ideal for women with smaller, flatter breasts and no sagging. When sagging is present, the chest muscle is cut and released from the ribcage at the bottom (along it's inferior insertion), allowing the implant to sit lower than would otherwise be possible, and therefore avoid the formation of a double bubble deformity.

The advantages of an implant placement below the chest muscle:

1. More natural look
2. Less visible implant in the upper breast
3. Lower risk of Capsular Contracture (undesirable implant hardening)
4. Lower risk of implant bottoming out (unfavourable downward movement)
5. Less visible implant rippling/wrinkling (natural folds in the shell of an implant; further information is given here)
6. Mammograms are easier to read (the implant is not directly behind the breast tissue)

The disadvantages of an implant placement below the chest muscle:

1. More discomfort during post-surgical recovery (this is minimal and should not be used as a determining factor in which approach is used)
2. Longer time for breasts to settle down into their optimal position and shape
3. Implant and breast movement during physical activity (when flexing chest muscles)

A sub-muscular pocket placement is more common than a sub-glandular placement, and is recommended for women who have minimal amounts of existing breast tissue. In such women, the chest muscle acts as a padded cover over the majority of the implant, so that it is less visible through the skin.

Over the Muscle (Sub-Glandular)

When a breast implant is placed in a sub-glandular pocket, the implant sits between the breast tissue and the chest muscle.

The advantages of an implant placement above the chest muscle:

1. Less discomfort during post-surgical recovery (this is minimal)
2. Quicker post-surgical recovery
3. Final (optimal) size and shape seen earlier
4. More bubbly, rounded (or push-up) look (known as the Fake Look)

The disadvantages of an implant placement above the chest muscle:

1. Higher risk of Capsular Contracture
2. Higher risk of implant bottoming out
3. Implant more visible
4. Implant easier to fee
5. Implant rippling/wrinkling more visible in the upper breast
6. Mammograms are harder to read (further information is given here)

A sub-glandular pocket placement is used only in women who have the moderate amount of breast tissue necessary to conceal the implant. It is recommended in women who have a mild degree of sagging (ptosis) or unusually shaped breasts. Sub-glandular implants help to change the shape of the breast more effectively than implants covered by the chest muscle in a sub-muscular pocket.

Dual-Plane Breast Augmentation

Dr. Jugenburg often performs dual-plane Breast Augmentation as it provides a beautiful, natural breast enhancement, even in women with very little existing breast tissue. In this approach, a Round breast implant is positioned below the chest muscle (pectoralis major) and partially below the breast tissue overlying the muscle, thereby giving the benefits of both a sub-muscular and sub-glandular pocket placement. This is achieved by releasing the bottom of the chest muscle (pectoralis major) from the ribcage (the inferior insertion) and the bottom of the breast tissue from the muscle to allow the bottom third of the implant to sit lower than the muscle in a sub-glandular position.

The uneven compression from the muscle across the implant creates a gentle, natural teardrop shape to the breast. Shaped implants (also known as Teardrop or Anatomic implants) would further exaggerate this effect in an unnatural way and are therefore not used with this approach.

The benefits of a dual-plane implant placement are:

1. Muscle coverage of the upper two-thirds of the implant lowers the chance of visible rippling/wrinkling and a visible upper implant border, while creating a gentle slope to the breast.
2. This breast tissue contours around the bottom third of the implant giving the breast a natu ral teardrop appearance and pleasing fullness.
3. Alteration of some of the chest muscle prevents the implants from being forced to sit too high (in many women their breast hang lower), therefore reducing the risk of double bubble being formed.
4. Alteration of some of the chest muscle allows for a subtle Breast Lift in patients with minor breast sagging (ptosis).
5. Implant placement can be performed with any incision (Trans-Axillary, Infra-Mammary or Peri-Areolar).
6. It may also be possible to achieve a fake looking breast enlargement, but this depends on how much of the tissue is released from the muscle, how much of the muscle is released from the ribcage, and the size of implants being used.

Which Placement Is Best for You?

During the consultation process, Dr. Jugenburg will examine you and explain to you which breast pocket placement will give you the best results. There is no single approach to implant placement that is ideal for every women. The placement and technique that Dr. Jugenburg uses for your Breast Augmentation will be chosen based on your existing anatomy and to meet your desired goals. Factors that may determine the best approach for you include:

1. How much your breasts hang on your chest (extent of sagging)
2. How much natural breast tissue you have
3. Whether or not your breast tissue needs to be repositioned relative to your chest muscle

For personalized advice on your breasts, please call us today on (647) 360-1975 to schedule your consultation.