Breast Implant Incision for Women with Small Bust

Around 20 million women have breast implants worldwide, a clear proof of the devices’ popularity among patients who want to improve their appearance or reconstruct their breasts following mastectomy or cancer surgery.

If used for cosmetic reasons, the common goal of patients wanting to have breast implants is to increase their bust size.

The bust size and appearance, natural tissue and fat, type of implant used, goals and expectations, and doctor’s expertise determine the appropriate incision sites in breast implant surgery.

Women with very small breasts (AA cup) should bear in mind that in breast augmentation, the “bigger the better” principle does not apply because of certain risks.  For instance, it is unreasonable and even precarious to use large implants that would give them DD cup due the higher chance of rippling and wrinkling.

And more often than not, small breasts are usually associated with small areola complex, making this incision site not ideal with the use of silicone implants, particularly large ones, because of the higher risk of visible scarring.

Silicone implants require longer incisions than saline implants because they are only available in pre-filled version.

By contrast, saline implants are filled with a sterile mixture of salt and water once inside the breast, for this reason small-breasted women may choose the areola incision if this type of implant is used.

Another good option for women with small bust is the breast crease incision, which is the easiest technique because it allows plastic surgeons to work close to the breasts unlike the armpit and navel incision sites.

However, there is one concern with the use of breast crease incision to augment a small breast.  First and foremost, women with AA cup often lacks a defined “fold” that separates the base of the breast from the chest; for this reason, there is a chance that the scar sits too high or too low that makes it visible.

But because most plastic surgeons are very adept with breast crease incision, low- or high-riding scar rarely occurs.

Meanwhile, the transaxillary or underarm incision is another good substitute for women with small breast and areola particularly if they choose saline implants.  While it is possible to use silicone implants, ideally they should come in small size so they can easily fit into the surgical slit.  

But whether a woman has small or large breast, the transaxillary technique is not used if there is an existing deformity because the distance between the incision and chest area can make the surgery extremely more challenging.  The same is true with the navel incision site. 

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.

Saline Breast Implants—Pros and Cons

Saline breast implants are filled with a sterile saltwater, for this reason, a leak will not result to serious health problems although patients will need revision breast augmentation to correct the deflated-looking bust.

Saline implants are not superior to silicone version, and vice versa.  Patients should realize that the most ideal option largely depends on their anatomical features (e.g., amount of breast tissue) and goals and expectations.

Meanwhile, these are the advantages of saline breast implants:

*  Shorter scar.  In the US, only saline implants filled at the time of surgery are available (currently there is no pre-filled saline implant).  Once the shell is inside the breast pocket, plastic surgeons inject this with a sterile saltwater before closing the incisions.

Because an empty shell can fit in a small incision, patients who will use saline implants should not be concerned with visible scars.

* Lower cost.  Saline implants cost less than the silicone version (around $900 to $1300 cheaper).  The difference in price is due to the reason that the cost of production for these implants is lower.

* No risk of silent leak.  In case of rupture, patients will immediately know it right away.  By contrast, women with silicone implants have to undergo regular MRI screening to detect silent leak.

* Slightly lower risk of capsular contracture.  This complication happens when the scar tissue surrounding the breast implants becomes too thick that it squeezes the devices.  Some studies suggest that women with saline implants are at lower risk of having this problem than patients with silicone version.  While the difference is just 1 percent per year, it can be as high as 10 percent after a decade of having the silicone implants.

On the other hand, saline implants have their own disadvantages such as:

* Less favorable cosmetic result.  Because saline implants are filled with only saltwater, women with little amount of breast tissue cannot achieve a natural result.  However, this is usually not a concern of patients with a moderate to significant amount of tissue and fat.

For patients with little breast tissue, silicone implants are the best option.

* Prone to sloshing

Unlike the silicone implants which are notable for simulating the natural “feel” of tissue, the saline version is prone to sloshing because it is only filled with water.  For this reason, some plastic surgeons intentionally overfill the shell to make the implants firmer.

* Natural deflation

One study has suggested that saline implants have a natural deflation rate of 1 percent per year due to evaporation and other factors.  By contrast, silicone implants maintain their for volume for years except in the event of rupture

Preventing Breast Implant Rupture

While there is no guaranty that breast implants will last a lifetime, plastic surgeons have come up with different techniques to at least prolong the devices’ lifespan and lower the risk of implant rupture.

In the event of implant rupture, the only solution is a revision breast augmentation; this procedure may involve replacing the implants with new ones or removing them without any replacement.

Meanwhile, these are some of the basic rules which can help patients prevent or at least lower the risk of implant failure.

* Choosing silicone implants over the saline version

Currently available silicone breast implants are less likely to rupture than saline because they are not prone to sloshing and wrinkling which are known to affect the shell’s stability.  Another advantage is that the silicone gel does not evaporate (unlike the saline) which means the patients can maintain their breast volume unless in the event of rupture.

The latest version of silicone implants—which have a more cohesive silicone gel than the one currently used—is almost immune to implant failure.  However, these breast implants, called the gummy bear implants, are not yet approved in the US although these are already used in Europe and Canada.

* When using salinei mplants

Rippling, which can compromise the shell’s stability, can be prevented in saline implants by slightly overfilling them.  However, this should be carefully done because too much filler can cause abnormal pressure on the device.

On the other hand, underfilling saline implants only has negative results because it can cause creases, leading to weak areas in the shell.

* Avoiding high trauma to the breast

Modern breast implants are very strong although they are still subjected to the effects of physical force.  Impact from car collision, sports injuries, and accidental falls may compromise the shell’s stability or may even lead to rupture.

* Consider the implant placement

Some doctors say that submuscular implant placement (placing the device under the pec muscle) poses a slightly higher chance of shell damage than the subglandular technique (positioning the implants over the muscle).  A good compromise might be the subpectoral placement.

* Use of Keller Funnel technique

In this technique, plastic surgeons place the breastimplants in a cone-shaped device and then squeeze it so the implants are transferred into the breast pockets.  Doctors use less force in this method than if they push the devices using their fingers.

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.

Patient Options in Breast Augmentation Surgery

The primary goal of breastaugmentation is not just about increasing the bust size but also making the result as natural as possible.  Fortunately, this is easier nowadays as breast implants come in different sizes, shapes, shell, filling, and projection, in addition to a wide range of surgical techniques used by plasticsurgeons.

Nowadays, three options in breast implant placement are available for patients: complete submuscular (under the muscle), partial submuscular (partially under the muscle), and subglandular (behind the tissue).  These surgical techniques have their own pros and cons which are carefully explained to women so they can decide for themselves.

The complete submuscular implant placement results to longer recovery and more pain during healing period because the pec muscles are stretched and pushed.  However, the technique provides countless of benefits such as more coverage to reduce the risk of implant wrinkling; more lifting effect; better mammogram reading; and lower risk of capsular contracture, which is a condition resulting to hardening of the scar tissue around the implants.

On the other hand, the subglandular implant placement results to shorter recovery because the pec muscle remains intact.  But since no muscle covers the implant shell, the technique is only ideal for patients with enough glandular tissue, fats, and skin.  Another consideration to make is that an ongoing ptosis (drooping) may be further aggravated because of the lack of strong “support.”

Meanwhile, the partial submuscular combines the benefits of subglandular and complete submuscular implant placements.

Aside from the implant placement, the type of implants can also have a significant impact on the final result.  For instance, women who want to achieve more cleavage are advised to choose round implant rather than the teardrop-shaped version, although the latter is more notable for simulating the natural contour of the breast.

Breast implants are either filled with saline or silicone gel.  For those who want to achieve a more natural “feel” and “look,” and women with a limited glandular tissue, the silicone implant is a better option; however, one downside is that the patients are required to undergo MRI screening every two years to detect any asymptomatic or “silent” leak.

On the other hand, women with saline implants are not required to have a regular MRI screening because a leak is easily manifested by deflated-looking breasts, making it possible to immediately seek revision breast augmentation.

Regardless if saline or siliconeimplants are used, their size should not only be based on one’s goal but also on her body-frame, amount of tissue and skin, and chest width.  It is important to note that a good plastic surgeon will not push the body’s limit by introducing implants that are too large for it.

Breast implants can be inserted via four incision sites: axillary (armpit), TUBA (navel), breast crease, and areola complex.  Patients should remember that the best surgical technique largely depends on their goals, acceptable risk level, and type and size of implants.

The axillary and TUBA incision sites require the use of an endoscope, which is a fiber optic camera attached to a large monitor.  Through this instrument, plastic surgeons can insert an empty saline shell inside the breast pocket and then fill this with a sterile saltwater solution.

But because the axillary and TUBA incisions work farther away from the bust area, there is a greater margin of error.  By contrast, the breast crease and areola incision sites provide surgeons with greater control over the final result of the surgery, making them a more popular choice.

Since there are many surgical options and type of implants available for women, breast augmentation typically involves lengthy consultation between patients and plastic surgeons.  In this way, doctors can also determine if the goals and expectations of a person with the surgery are plausible and achievable.