New York Breast Expert: Breast Implants
THE BREAST IMPLANT
PLACEMENT OF THE IMPLANT
A breast implant can be placed behind the breast--above the muscle (sub-mammary
placement) or behind the pectoralis major muscle of the chest (sub-pectoral
placement). Since the pectoralis muscle does not completely cover the implant,
a third method uses smaller chest muscles to cover it entirely. This variation
is rarely done. An estimated 60% of the plastic surgeons in America place the
implant above the muscle and 40% place it behind the muscle. I believe as the
majority does in placing it above the muscle, (directly behind the breast) except
in a very few circumstances. Of the 114 patients on whom I did a breast enlargement
last year, I put only three of them behind the muscle. Here are the reasons
for my preference for placing the implant over the muscle:
1) Aesthetically pleasing: Most importantly, done correctly, an implant looks
perfectly natural over the muscle, as that is of course where nature put the
breast. Placement behind the muscle often gives too much upper pole fullness
that not only looks unnatural, but can sometimes cause the nipples to appear
to point downward. This deformity is more likely to appear when the implants
are placed from an incision under the arm.
2) Local anesthesia option: Over the muscle, the surgery can be done with intravenous
sedation and local anesthesia which is safer and less expensive, but of course
general anesthesia is available. Placement behind the muscle always requires
general anesthesia or a complicated series of nerve blocks.
3) Preservation of the pectoralis major muscle: When implants are put behind
the muscle, the inner attachment of the muscle must be cut to allow space for
the implant. Not only does this increase the risk of bleeding, but also it severely
weakens the pectoralis major, the main chest muscle. In the past year and a
half I removed five sets of implants placed behind the muscle by other surgeons
and put them in front of the muscle because they looked so abnormal. In all
these instances, the pectoralis muscle was paper thin, having been destroyed
either by the pressure of the implant beneath it, or by the detachment of the
muscle. A muscle that is not attached at both ends cannot contract, cannot be
exercised, and thus atrophies. Cutting the muscle also increases the risk of
bleeding after the surgery.
4) Natural feel: The only reason for placement behind the pectoralis is that
its proponents believe that it causes less capsular contracture (apparent hardness
of the implant to be discussed later). This is very controversial as some studies
have shown this to be true and others have shown no difference in the feel of
the breasts no matter where they are placed. A colleague of mine says that he
has done over 5000 augmentations, probably more than anyone in the country.
He has placed implants in both positions and strongly believes that there is
no difference in the feel of the breasts and now places them exclusively above
the muscle.
In addition, because of the anatomy of the pectoralis muscle, it can only cover
about half of the implant. Since the capsule surrounds the implant completely,
it makes no sense that sub-muscular placement can prevent capsular contracture.
The same is true about the complication of rippling.
5) Less pain: There is much less post-operative pain with the implant placed
above the muscle. No strong narcotics are usually necessary; pain medication
is usually taken for only the first two days, and patients can return to work
in two or three days. Under the muscle placement is very painful requiring strong
narcotics for a week and often two, and a week away from work is usually necessary.
To summarize the disadvantages of putting the implant under the muscle (sub-pectoral):
it virtually destroys the muscle; it can appear very unnatural; there is increased
risk of bleeding; it is very painful for a week or two; the implant is only
about half covered by the muscle. And in my opinion, it does not make the breast
feel softer or prevent rippling.
SIZE OF IMPLANT
The size of the implant is very important. You might want to be very large,
or, as with most women, request just a cup to a cup-and-a-half size larger.
Of course there is no standard cup size--every manufacturer has its own idea
of what a C cup is, for example. There is no standard, so asking for a specific
cup size will only give your surgeon an idea about how much larger you want
to be. The implants are measured by the volume of fill material that they hold,
but as a general rule, 200 cc. makes an enlargement of about one cup size in
a smaller breast. Standard implants range from 125 cc. to 800 cc. when filled.
COVERING OF IMPLANT
The outside surface of the implant can either be smooth or “textured",
meaning rough. The textured surface is meant to break up the direction of the
fibers that form the capsule so that they cannot contract in unison and cause
hardening. I found that with textured implantsI had a much higher incidence
of hardening than I did with the smooth-walled ones. But some studies have shown
results to the contrary. There are also different types of texturing.
There are other serious problems I have found with textured implants. Because
the manufacturing of a textured implant requires that its wall be thicker, if
the implant ripples, it does so with a vengeance. Even more distressing, there
was a high incidence of leakage with the textured implants. Finally, if textured
silicone is used, the rough surface requires a large incision because the implant
will not slide through a small one.
SHAPE OF IMPLANT
Implants come in various shapes. They are commonly round. They may have a high,
medium or low amount of projection. They can also be shaped like an oval or
tear drop. These so-called anatomical shapes have more projection in the lower
pole than in the upper. This is meant to mimic the natural shape of the breast.
However, years ago, an experiment was done where one breast was enlarged with
a round implant and the other with an anatomical one (with the patients' permission,
of course). Six months later, independent observers could not tell the difference.
The real problem with oval-shaped implants is that if they are smooth-walled,
they can rotate. When that happens, the breast can appear terribly misshapen.
To prevent this, it is necessary to use a textured implant, which has the disadvantages
just mentioned.
Next: Breast Implant Risks
from Dr. Bellin's Beauty Science (copyright 2001)
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