San Diego — While the great majority of breast augmentation surgeries are performed placing the breast implant under the pectoralis muscle, surgeons are now exploring possible advantages of placing the implants under the superficial fascia of the muscle. They say the results are better than expected.
Traditionally, subpectoral placement has been favored because there was less of a rippling effect, doctors saw less scar tissue formation with the use of the old silicone implants and patients could more easily undergo a mammography.
Speaking at the American Academy of Cosmetic Surgery (AACS), cosmetic surgeon Patrick McMenamin, M.D., Sacramento, Calif., says these perceptions may be outdated, and subfascial placement offer various patient advantages. Dr. McMenamin responded to each of the statements in support of subpectoral implants:
- Less scar tissue. Frequently, seeping of silicone material into the tissue seemed to stimulate the scar tissue formation.
"There is less scar tissue with any implant used today than in the past — even with silicone — probably because of an increased density of the current silicone and the shell," Dr. McMenamin explains. "There is the same amount of scarring with saline implants whether they are placed above or below the muscle. The individual's scar pattern is a bigger determinant of scar tissue formation."
- Mammograms are better. "There is no question it is easier to read mammograms with subpectoral implants, but many studies in the literature show that delays in diagnosis, delays in treatment or death from breast cancer are not affected by implants."
Dr. McMenamin says women with implants actually have a lower incidence of breast cancer than women without implants because they typically have less breast tissue.
- Less rippling. A study published by Howard Tobin, M.D., showed that 40 to 50 percent of women with implants under the muscle still had rippling. Secondly, even with larger pectoral muscles, the muscle only covers 30 to 40 percent of the implant (American Journal of Cosmetic Surgery. 2002;19(No. 1): 15-21).
"With saline implants, there will be rippling. It is really a matter of degree, and the patient must decide if they will tolerate this," Dr. McMenamin adds.
He says if the importance of those three factors are negated, then surgeons have to look at both methods of placing implants and look at what other advantages and disadvantages exist.
Rippling can occur as a result of either subfascial or subpectoral placement. It is a matter of degree, patient perception and a reflection of individual tissue properties and implant size, according to Dr. McMenamin.
Dr. McMenamin divided the assessment of the implants into four categories: appearance, movement, settling and rippling.
- Appearance — "Here, there is no comparison," he says. "When you put the implant under the muscle, you get a bulge on top. It's what I call the 'boing' or 'baseball' look. Under the fascia, implants look more natural."
- Movement — The tightening of the muscle forces the implant to rise up higher on the chest wall when placed under the muscle, and in some people it stays higher. Women working out at a gym note varying degrees of movement.
"When some women who have subpectoral implants flex their pectoralis muscles, the implants move up and out toward the armpit and they can actually get a visible and unattractive crease in the top of the pectoral muscle. I have not seen that with subfascial placement. Under the fascia, it doesn't ride as high, the recovery process is easier and the healing, more predictable."