21 Oct 2012

Breast Augmentation: Under vs. Over (part 3 of 7)

Breast implant under (right) and over (left) pectoral muscle

Beautiful results from breast implant surgery results from excellent surgical technique, but it also relies on informed decisions by our patients. One decision you must make is whether to go under (sub-pectoral) or over (sub-mammary) the pectoral muscle. Implants put under muscle will cause more discomfort for the first few days, as the muscle is partially divided and must stretch over the implant.

The implant is also pushed away from the midline by the pectoral muscle as it attaches to the sternum (breastbone), and this appearance will be exaggerated by exercise. This is a problem for patients who are looking for ‘lots of cleavage’, or are concerned with their appearance while exercising.

On the plus-side, a sub-pectoral implant may look and feel more natural when the chest is at rest, because the top edge of the implant is contoured by the overlying muscle (see photo, patient’s right side), and the unnatural feel (especially a problem in thin patients or with saline implants) of the implant is hidden under more tissue. This may also explain why capsular contracture is less often experienced as a problem in sub-pectoral implants. If there is concern about the implant sliding down the chest or further stretching out loose breast tissue, a textured implant under muscle is a good choice as it ideally will anchor to the muscle and chest wall and put less pressure on the gland and skin of the lower breast. Implants placed in a dual-plane, with only the top of the implant completely covered by muscle, lie in the correct position immediately after surgery. Implants put completely under muscle (e.g. through an armpit incision) will typically need a lot of massage to stretch the tissues during healing until the implants find their proper position on the chest.

Yes, many patients at our Toronto cosmetic plastic surgery practice leave the decision of Under vs. Over to us, but your participation in the surgical plan may help you obtain a result that is perfect for you.

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Michael Kreidstein, MD, MSc, FRCS(C)

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