Subpectoral vs Submuscular

[lynn80]

My sister and I both got breast augmentations earlier this year but live in different areas/had different doctors. Our bodies/presentation preoperatively were very similar. My implants were placed subpectoral and hers submuscular. We both received 325cc mod plus silicone, and are 5'6 approx 115 lbs.
After 6 months, one of my implants now sits lower on my chest and the bottom half of the implant is very palpable (Apparently the scar tissue did not form well on that side and the tissue stretched). I had very little breast tissue to start and I know that is part of it but this left implant really feels like it slipped out from under the muscle or something. At my 4 month appointment my PS said he can lower the crease of my right breast to match the left but my right breast is exactly where I would want it to be and the more I think about it, the more I don't want to do it. I am seeing my doctor next week and the plan was that I would be scheduling a revision at this appointment for December (8 months after original surgery).

I recently got together with my sister and the difference between our results is remarkable. Her implants are well supported, not palpable, and symmetrical...so I was thinking maybe this would be a solution for my problem.
Next week when I see my surgeon I would like to talk to him about this option. Prior to my augmentation that he places most implants subpectorally and sometimes subgladularly and that there isn't really a totally under the muscle implant, I imagine this placement isn't a hidden secret so I am not sure why he didn't mention it. I understand that even with the submuscular placement, the implant is not completely under the muscle, but is certainly more supported, which is why I was thinking it mighthelp me. . Is there a downside to this placement that I might be overlooking because it sounds so much better? I looked at your website, and see that you do quite alot of augmentations using this placement. I like my surgeon, but I do not want my breasts low on my chest nor do I want to live with lopsided breasts.
I would like to discuss other options with him next week, including this placement, but I am not sure how to do so without sounding like I am telling him how to do his job/offending him. He might not even feel comfortable doing this anyway, I don't know if it is a surgical technique that is more complicated. It just seems like there has to be another solution besides lowering my right breast. Any information you can provide about this would be appreciated. Thanks in advance!

[drdonrevis]

Good afternoon,

Your post is the perfect example of the difference between the two approaches. Many PS make claims that there is no difference, that there is no way to place implants totally under the muscle, blah blah blah.

Most likely this is because they don't want to take the extra time to create a totally submuscular pocket or they don't understand the procedure- but the advantages in my opinion are dramatic.

The difference between the two approaches is the lower outer one third of the breast- simply put, your sister's implants are supported on the bottom by muscle and yours are not. This means that yours can bottom out, and since there is less tissue coverage rippling and implant palpability are much more likely.

You have bottoming out on the left side. The easy approach is to create bottoming out on the right side, but do two wrongts make a right?

The proper correction is an internal bra procedure, which reattaches the tissues in the lower outer third of the breast, providing better support for the implant, and lifting it back up to where it belongs.

This is the most common revision that I perform, 2-3 times a week.

It can be a sensitive topic to discuss with your PS, but he should be willing to have an honest discussion regarding any concerns you may have. Tell your PS you have done some research and feel that you have bottoming out and that you would like to consider a bottoming out repair.

However, make sure your PS also knows how to do this procedure- just ask him how many times he has performed a revision for bottoming out, and what is his success rate? Plastic surgeons tend to love first time breast augmentation's and call themselves breast augmentation specialists but in fact don't understand the potential problems or how to fix them.

Sincerely,
Don Revis, MD
www.InternalBra.com

[lynn80]

Thank you for your thorough response. I will be sure to ask my PS about the things you suggested. I know my surgeon has a great reputation in my area for primary augmentations but have not heard alot about him as far as revisions.

Since you do so many procedures using the submuscular approach I have an additional question for you. Is there a significant with the results your patients have difference between silicone and saline? I went with silicone as suggested by my surgeon because I had such a small amount of breast tissue. He said I would have significant rippling with the saline. I am curious if I were to switch from subpectoral to submuscular if I could switch to saline and get good results? I looked at the before and after pictures on your website and several of your patients had very small breasts beforehand and seem to look great with saline. I do not here frequently of people going from silicone to saline.

[drdonrevis]

Hi again,

I'll get right to your questions:

1) "Is there a significant with the results your patients have difference between silicone and saline?"

The submuscular placement of implants certainly minimizes the difference between saline and silicone. However, there are still some differences present. In someone who is very thin, saline will still be more likely to ripple than silicone, although the rippling rate with this technique is extremely low when compared to any other technique.

Secondly, saline will provide a more youthful, perky firm look and feel to the breasts whereas silicone provides a softer more natural appearance.

2) "I am curious if I were to switch from subpectoral to submuscular if I could switch to saline and get good results?"

Two problems here. First, most patients are not happy going from silicone to saline because of the increase in firmness.

Secondly, the subpectoral technique actually divides the connection of the muscle to the chest wall in the lower outer pole of the breast, making it impossible in most cases to switch from subpectoral to submuscular. It is easy to place implants submuscularly from the beginning or after a subglandular placement, because in both instances the muscle has not been disturbed. Once it has been cut, however, it's a different situation entirely.

Best wishes!
Don Revis, MD
www.SouthFloridaPlasticSurgery.com

[lynn80]

Hello Dr. Revis,

I follow you 100% with your first response but....What course of action would you typically take for a new patient that came in to your office with malpositioned/bottomed out subpectoral implant?...Since they can't typically be positioned submuscularly at this point?

I sure do wish I lived in Florida!

Thanks again!

[drdonrevis]

Good afternoon,

This is the most common problem I repair, 2-3 times a week, with an internal bra procedure- see www.InternalBra.com for more details and photos.

Best wishes,
Don Revis, MD
www.SouthFloridaPlasticSurgery.com

[oceanrain]

Originally Posted by drdonrevis

Good afternoon,

Plastic surgeons tend to love first time breast augmentation's and call themselves breast augmentation specialists but in fact don't understand the potential problems or how to fix them.

Sincerely,
Don Revis, MD
www.InternalBra.com

Finally a PS who knows what he is talking about