FAQs About Breast Implant Placement

The overall result of breast augmentation surgery is largely affected by implant placement.  To better understand this issue, the California Surgical Institute has provided a list of most frequently asked questions:

1.  Question:  What are the three basic types of breast implant placement?

Answer:  The implants can be placed under the tissue (subglandular or over-the-muscle placement), behind the muscle (submuscular or under-the-muscle), and behind the tissue and partially under the muscle (partial submuscular placement).

2.  Q:  What is the most ideal implant placement?

A:  The most ideal implant placement is dictated by a patient’s overall anatomical features including the amount of tissue and fat to work with, and her goals and expectations.

 3.  Q:  When is subglandular or over-the-muscle implant placement ideal?

A:  In general, this breast augmentation technique is ideal for women with ample amount of tissue and fat that provides enough “coverage” to prevent visible and palpable wrinkling.  And because the top edge of the implant has little tissue, the method provides a distinct cleavage line.

4.  Q:  When is submuscular or under-the-muscle implant placement ideal?

A:  The technique is highly ideal for patients with little amounts of tissue and fats who are prone to wrinkling and rippling.  Also, many plastic surgeons believe the implant placement is recommended for women who are concerned with sagging or bottoming out since the weight of the implant is supported by the muscles rather than by tissue and skin alone.

The submuscular placement is also ideal when using large breast implants (e.g., full D cup) because it prevents visible and palpable rippling.

To further reduce the risk of rippling, doctors recommend silicone implants, which are filled with a cohesive gel notable for simulating the feel of breast tissue and fats.  By contrast, women with little tissue are often advised to stay away from saline implant due to its watery consistency, thus increasing their risk of wrinkling.

Using smaller implants when dealing with small-breasted women is another effective way to reduce the risk of rippling and wrinkling.

5.  Q:  Is it true that women with submuscular implant placement can go braless without having to worry about sagging?

A:  Technically speaking, the answer is yes.  However, many plastic surgeons believe the breasts still need a good support to prevent or at least postpone sagging.

6.  Q:  Why is it that submuscular implant placement often results to longer recovery and more postoperative pain and discomfort?

A:  In this technique, the muscle is literally compressed and pushed by the breast implants, leading to more swelling, pain, discomfort, and longer recovery than if the subglandular implant placement were used.

7.  Q:  How long does it take for the implants to settle naturally?

A:  If the submuscular implant placement were used, it would take longer (several weeks or even months) for the implants to settle down naturally than if subglandular technique were used.  But regardless of which method is used, patients should expect that their newly augmented breasts will appear unusually firm and that they will sit higher on the chest.

Within a few weeks or months, the breast implants will settle downward, leading to a natural appearance.  In some cases, a strap is wrapped around the chest area to achieve a more desirable result.

8.  Q:  Does implant placement affect the rate of capsular contracture or tissue hardening?

A:  Some plastic surgeons believe that submuscular implant placement somewhat reduces the risk of capsular contracture because it limits the contact between the implant shell and tissue where most of the bacteria live.

However, this is just an anecdotal observation rather than a scientific conclusion.  And to put it succinctly, capsular contractures are quite unpredictable and may happen to some patients, regardless of which breast augmentation technique is used.

9.  Q:  Does implant placement affect the accuracy of breast screening test?

A:  In general, breast implants—no matter what type of placement is used—make it more challenging to perform breast X-ray and mammogram.  Fortunately, many radiologists nowadays have experience screening women with these devices.

Most experts agree that the submuscular implant placement is less likely to obscure mammogram readings than the subglandular technique. 

10.  Q:  Does a certain implant placement prevent symmastia or “uniboob?”

A:  The implant placement will not affect a patient’s risk of symmastia, a condition in which the breasts settle in the middle of the chest.  This problem happens if the implants are “inappropriately” large or there is over-dissection of the muscles at the breast bone.

As with any problems caused by implant displacement, symmastia can be only treated with revision breast augmentation surgery.

Thinking About Having Bigger Breast Implants?

As its name suggests, breast augmentation surgery aims to increase the bust size and a fuller appearance especially in the upper and medial cleavage.  However, it does not necessarily mean that you can go as large as you want because several factors can play a role in your ability to accommodate larger implants.

Currently, the biggest implants available are filled with 800 cubic centimeter or cc of saline or silicone gel.  Going larger than this size means you will need a customized implant, which means additional fees.

But common sense suggests that implants larger than 800cc do no guaranty better results or more beautiful appearance.  In fact, most self-respecting plastic surgeons would likely decline a patient whose aesthetic goals are too extreme that these will push the body’s limits.

While breast implants are reasonably safe, this may not be the case if yours would be too large for your tissue and fat to accommodate.  Imagine that an implant shell needs “enough coverage” to prevent palpable rippling and visible wrinkling, and using extreme sizes can lead to this kind of problems.

And if you are leading an active lifestyle, unreasonably large breast implants will definitely not work for you.

A “reasonable” size should not just depend on what you want to achieve with breast augmentation.  First and foremost, you should also consider certain anatomical features such as chest width, waistline, and natural breast tissue and fat.  Always bear in mind that the less tissue you have, the more ideal it is for you to choose small- to moderate-sized implants.

By considering your anatomical features—including your body frame (e.g., petite, athletic, big-boned)—it would be easier to achieve a more natural appearance.  Take note that the “heavy top look” which is arguably popularized by Pamela Anderson is no longer the in thing; in fact, the star has been rumored to undergo a revision breast augmentation to downsize her implants.

Even Dolly Parton and Denise Richards were reported to have had breast augmentation to downsize their implants and achieve a more natural look.

Even before consulting with a plastic surgeon, you should be 100 percent sure on the bust size you want to achieve; in this way, you will most likely be satisfied after the surgery.  Always bear in mind that a significant number of revisions happened because the patients thought they have gone too big or too small, so making it right the first time is crucial. 

Breast Contour After Augmentation Mammaplasty

When discussing breast implants, the size is not the only issue patients should focus upon.  They should also bear in mind that the shape and profile of the device, in addition to the appearance of their chest and amount of tissue and fat, can have a significant impact on the final result of breast augmentation surgery.

Breast implants come in two shapes: round in which all the sides are symmetric, almost resembling the contour of an M&M candy; and anatomical in which the lower portion has more volume than the upper part, leading to a teardrop appearance.

To date, round breast implants are more popular than the anatomical version not only because they are cheaper but also they are less likely to cause “aesthetic” problems.  In fact, they can rotate inside the breast pocket and the shape of the chest will still not appear distorted.

By contrast, contoured or anatomical breast implants can lead to deformity in case that they rotate inside the pocket.  And because of this risk, they only come in textured surface which aims to prevent gross movement; however, the same design that prevents implant rotation has its own downside including higher risk of rippling, traction wrinkling, and failure.

As mentioned earlier, implant profile—or its projection off the chest wall—also has an impact on the breast contour after the implant surgery. 

Patients should take note that by using the right implant profile, they can avoid having breasts that appear too pointy or “unusually round.”  Fortunately, most board-certified plastic surgeons today can tell which one can provide the most desirable and natural result by simply looking at the patients’ body-frame.

For instance, high profile implants, which offer more projection but come with a smaller base, can result to a pointy appearance if they are used by women with a wide upper body, thereby leading to a very unflattering appearance.  On the other hand, the design provides a natural outcome if used by patients with a narrow frame.

For patients with a broad torso, it has been sacrosanct to use low profile implants, which offer less projection but come with a wider base so they can fill up more space.

Aside from the implant type, the appearance of the breasts and amount of tissue and fat also affect the outcome of breast augmentation surgery. 

Patients with a fair amount of tissue and fat tend to enjoy a more natural result with the use of saline implant, which has a watery consistency.  By contrast, women with limited tissue and fat would likely end up having a dome-shaped breast if this implant type is used.

Fortunately, a dome-shaped breast can be avoided with the use of silicone implants particularly when dealing with patients whose tissue and fat are quite limited.  This is because the implants are filled with a cohesive gel designed to simulate the consistency of the natural glandular tissue.

Also, the breast contour after surgery is affected by the structure of the chest.  For instance, women who have a pigeon chest, which is associated with the protrusion of both the sternum and ribcage, should expect that it would be more difficult for them to achieve a prominent cleavage (both upper and medial cleavage) than patients in the general population.

Can Silicone Breast Implants Correct Mild Drooping?

Silicone breast implants are increasingly becoming popular these days as they provide a more natural result than saline implants.  This is not surprising because they are filled with a cohesive silicone gel designed to replicate the “feel” and move of glandular tissue and fats; another bonus is that the filling does not evaporate—unlike the saline solution—which means the patients can maintain their breast volume unless in the event of leak or rupture.

The good news is that breast implants—particularly the silicone-filled versions—can correct mild or pseudo ptosis (sagging) which is caused by breastfeeding.  It happens when the mammary glands put pressure on some glandular fats, but after the enlargement resolves, the breasts somewhat “deflate.”

On the other hand, true ptosis is caused by stretched and damaged suspensory ligaments in the breasts.  Oftentimes, the problems can only be addressed by mastopexy or more commonly referred to as breast lift; this can be performed as a standalone procedure or as a complementary to breast implantsurgery.

To correct mild or pseudo ptosis, it is highly recommend to use small implants (300 to 350 cubic centimeters would be the right range) because introducing large ones can aggravate the problem as the tissue is forced to carry the extra weight.  And over time, the stretched tissues will worsen.

By using large implants, there is a higher chance that the patients will need breast lift sooner rather than later.

It is important to note that even small implants can provide upper pole fullness in the breast, the area which is often affected by childbirth and breastfeeding.  But as mentioned earlier, silicone implants are better than the saline versions because they do not have a natural deflation rate.

By contrast, saline implants have been found to lose about 10 percent of their volume after a decade because of evaporation and other factors.  This simply means that patients with these devices are more likely to need revisions sooner than those who have silicone implants.

Meanwhile, there is still a debate whether the subglandular or submuscular implant placement provides more lift.

In the subglandular implant placement, the device is positioned above the muscle which is believed to provide a more lifting effect.  But one downside is that only the tissue and skin support the implant, something which may aggravate the ongoing ptosis.

On the other hand, the submuscular implant placement is said to prevent future ptosis because the device, which is positioned under the pec muscle, is being supported not only by the tissue and skin but also by a thick amount of muscle.

Breast Implant Size and Things to Consider Before hand

The size of breast implants is measured via cubic centimeter or cc instead of “cup” since every bra manufacturer follows its own standard.  Meanwhile, it is important to note that the volume is not the only thing that affects the final results as there are other contributing factors such as implant profile, shape, and placement.

During the previous years, a significant number of women who asked for breast augmentation wanted larger implants even if it meant having a “heavy” top look.  However, plastic surgeons today see a shifting trend toward smaller sizes to achieve the natural look.

The growing trend can be seen on some Hollywood celebrities who replaced their breast implants with smaller ones.  For instance, Denise Richards and Pamela Anderson have been reported to have undergone revision plastic surgery to downsize their implants.

Another good example is Kate Hudson who has been reported to receive small breast implants in 2010.  And because of the subtle changes in her bust size, no one would even know that she had the procedure if not only for her previous photos and videos showing how flat-chested she was back then.

As a general rule, very large implants will obviously look “fake” in addition to higher risk of complications as the body, especially the back and upper torso, has to carry more extra weight.  For this reason, a good plastic surgeon will make every effort to convince his patient that inappropriate implant sizes can lead to many problems.

The problem with inordinately large implants is that they may lead to premature sagging and tissue thinning as the breasts are forced to carry more weight.  To correct such complications, a revision plastic surgery—which may involve implant replacement or permanent removal of the device—is the only effective solution.

For thin patients, particularly those with limited amounts of glandular fats and tissue, very large implants can significantly predispose them to visible and palpable rippling, or sometimes even traction wrinkling especially if they will receive the textured implants with large size “graininess.”

Another consideration to make is that large breast implants can upset the center of gravity of women, which can affect the way they move.  With this consideration, athletes and patients who live an active lifestyle are generally advised to choose smaller implants to maintain their performance and good posture.

Because of the risk of excessively large bust size, implant manufacturers in the US do not sell silicone breast implants that are over 800cc.

French Implant Manufacturer Warned by US 10 Years Before the Scandal Broke

It has been estimated that 300,000 women have the defective breast implants manufactured by the now bankrupt French company Poly Implant Prothese (PIP).  According to reports, the devices are extremely prone to rupture as they lack a protective coating that prevents silicone gel from migrating to other parts of the body.

Fortunately, the defective silicone implants were not approved and sold in the United States.  In fact, the US Food and Drug Administration has warned PIP in 2000—10 years before the scandal broke—about its failure to follow “good manufacturing practices.”

However, reports show that 80 percent of PIP breast implants were exported to other countries including UK, Chile, Germany, Venezuela, Spain, Argentina, Colombia, and Brazil.

According to the FDA warning sent to PIP founder Jean-Claude Mas, the company’s plant in La Seyne-sur-Mer in the south France has 11 deviations from “good manufacturing practices.” 

The organization also warned him about the “adulterated” saline breast implants, and cited his company’s failure to investigate the deflation of its products in addition to failure to report 120 complaints in France and other countries.  Currently, there is global manhunt for the 72-year-old company founder who is a former butcher.

With the FDA warnings, consumer groups in France ask why their authorities did not conduct an investigation on the safety of PIP’s breast implants.

The US is one of the countries that require very strict guidelines when it comes to implants and devices used in cosmetic plastic surgery.  In fact, Mentor and Allergan Natrelle are the only two companies allowed to manufacture and sell breast implants in the country.

To allay the concern of patients in the US who had breast augmentation surgery, the American Society of Plastic Surgeons (ASPS) has released a statement saying that the defective implants did not reach the country.  The organization added that only those who had the procedure outside the US should be concerned with the defective product.

Because of the fiasco, the French government has promised it will pay for the implant removal surgery of women affected by the defective products.  It has been estimated that 30,000 patients in the country had the PIP silicone-filled implants.

Reports show that PIP’s cheap silicone implants were filled with an industrial silicone gel designed for mattress rather than for human.

On the other hand, the British government still insists that there is no need to require all women with PIP’s silicone implants to undergo implant removal surgery although they are advised to immediately consult their doctor to determine if there is a leak.