Placement of the implant is one of the big decisions you will have to make as you consider breast augmentation. Above or below the muscle are the choices. So let’s dig into the issues here. First, a little history. In the 1960’s, 70’s, 80’s up to the moratorium on silicone breast implants in 1992, almost all of the implants used were silicone filled and they were placed on top of the muscle. That was the norm. Then questions arose about the safety of the silicone and they were voluntarily withdrawn from the market by the implant manufacturers and studied with the FDA until their re-emergence in 2006. During this time saline filled implants were used and initially these too were all placed on top of the muscle. Then the problems of rippling and wrinkling emerged. Saline implants wrinkle and ripple more than the gels, that’s just what they do, and so the idea of placing them behind the muscle arose. So from the early nineties on, placement of an implant behind the muscle became the norm. Then in the fall of 2006 today’s cohesive gel implants were re-released by the FDA which created our ‘placement’ question. Gel implants can go above or below the muscle. If a woman has little or no breast tissue I would never place the implant above the muscle. It’s just too obvious. If she is a big B or more to start, I think it’s reasonable. Now, the big advantage of going above the muscle is recovery. If we don’t lift that muscle up it just doesn’t hurt as much after. It doesn’t hurt nearly as much. But, by going on top of the muscle you also open the door to two problems that are much less likely if the implant is behind. These are capsular contracture and interference with Mammograms. The risk of capsular contracture, which is the formation of a thick scar shell that can deform the shape of the breast and make it very hard, is about 12 or 13% on top of the muscle but less than 1% below the muscle. Implants on top of the muscle also make it more difficult for the radiologist to see the whole breast when they are reading your mammogram films. This could result in an abnormality being missed or more likely the need for additional tests, like an ultrasound, spot compression views, or maybe even a MRI. So what do I recommend? For most breast augmentation patients I say the extra recovery is worth it. Yeah you will be more sore the first 3-4 days but after that you get the lifelong benefits of the submuscular placement.

When you go for your consultation for breast augmentation there are really 3 key decisions you have to make, other than the decision to actually do it or not. These 3 are implant type, saline vs silicone, implant placement, above or below the muscle, and implant size. What constitutes “too big” is a fairly subjective answer in some ways and in others there is a well defined answer to the question. The subjective component is patient based. In other words, you need to decide how you would like to look. Do you want a very subtle change, something in the middle, or do you want the result to look obvious. Most of my patients simply want to balance out their figure and will choose an implant size that accomplishes that. In fact, a lot of my patients don’t look very different in their clothes after surgery because they had been wearing bras with so much padding they were already ‘augmented’ via their bra choice. Now, if you ask me what is “too big” I am looking at things from a completely different perspective. For the surgeon, the key issue is the base width of your breast. Base width is the measurement from the top of the breast down to the crease and from the edge of your breast bone to the side of the breast. In most women the width of the breast will range from 13 to 14 cm on the small side up to 16 or 17 cm. A base width of about 15-16 cm is considered “normal”. The reason that this measurement is so critical is that in order to achieve the most natural results I need to use an implant that will fit within the breasts natural boundaries. When you exceed the boundaries it is fairly obvious. When the implants are under the muscle, there is only so much room between the nipple and where the muscle inserts onto the breast bone. So, for instance, in a woman with a 14 cm breast width, there is only 6 or 7 cm of space between the nipple and the breast bone. If we use an implant that is 14 or 15 cm wide there is simply no room to center the implant behind the nipple. The only place the implant can go is further to the side which translates to under your arm. Like wise, if the distance from the nipple to the crease is limited, the mid point of the implant will be above the nipple giving the look of an implant that is too high. My goal, in order to give you the most natural result, is to center the implant directly behind the nipple. Thus, choosing an implant whose width matches that of your breast is critical.

Lee Corbett, MD

Medical Director, Corbett Cosmetic Aesthetic Surgery and MediSpa