There are a number of anatomically unique places in the chest wall that breast implants can be placed effectively. Historically, implants were placed within or under the breast tissue. Due to the inherent tendencies of early silicone gel-filled implants to form severe scar tissue, and the subsequent saline-filled implants forming wrinkles, surgeons began placing implants under the pectoralis major muscle. For the most part, these two positions have been prominent through the years, with the exception of two modifications that play a minor role today. Each position is detailed below with pros and cons.
The Subglandular Position
This is the first and most logical placement of breast implants. This method has slowly phased out over the years, with the exception of women with larger, more sagging breasts and female body builders.
- Muscular contraction: Perhaps the most indisputable benefit is that the implant is not displaced by muscular contraction, which causes submuscular implants to separate or even become deformed. Subglandular implants are placed atop the pectoralis muscle, therefore leaving the muscle undisturbed.
- Recovery: Pain, discomfort, and recovery are arguably less severe. However, modern techniques and protocols with submuscular placement have minimized and even obviated the need for narcotic pain medication in recovery.
- Greater lift: Women with more saggy breasts seem to benefit from subglandular placement because of the immediate lift of the breast tissue and skin.
- Nipple position: Typical results frequently show persistently low nipple and lower breast position, which invariably worsens over time.
- Visibility and appearance: The implants are closer to the surface of the breast and are therefore more palpable and visible, making wrinkling and rippling noticeable. This problem is exacerbated with larger implants and saline implants, as well as tissue stretch and thinning that occurs over time. This gives the implant a very "bubbly" appearance.
- Capsular contracture: This is a common problem that causes thickening and shrinking of the scar capsule around the implant. It is most prevalent in this position.
- Mammographic difficulty: During a mammographic evaluation, it can be more difficult to visualize all the breast tissue and thus requires additional views.
Although the benefits of the subglandular placement of breast implants are debatable (or perhaps at least suitable for a small group of women), the limitations are clearer and indisputable.
The Subpectoral Position
This is the most common position for breast implant placement today. It has three very important benefits that make it arguably the best place to put breast implants.
- Less visibility and lower risk of rippling/wrinkling: Because the pectoralis muscle covers much (but not all) of the implant's surface, it is less visible or palpable in the breast, especially in the inner and upper regions. This gives the breasts a much more natural appearance, with a lower risk of rippling or wrinkling.
- Lower risk of capsular contracture: Another very important benefit of subpectoral placement is that there is a substantial reduction in the risk of capsular contracture compared to the subglandular position.
- Mammographic visibility: There is better mammographic visibility of the breast tissue when the implant is under the pectoralis muscle.
- Deformation: A fair number of patients will have moderate to significant dynamic mobility or deformation of the implant and breast with contraction of the pectoralis major muscle. This is not universal, though medical professionals opine that it is associated with incomplete muscle division, larger implants, and the nature of the individual’s scar capsule that forms.
- Greater discomfort and longer recovery time: As mentioned previously, there is a general consensus that discomfort is greater and recovery is longer compared to subglandular placement. However, with proper implant size planning and meticulous surgical technique using electrocautery, discomfort is treatable with ibuprofen and a full recovery can be as short as one to three days.
The Total Submuscular Position
The placement of the breast implant into a total submuscular pocket, which not only includes the pectoralis major but also the serratus anterior and rectus abdominus muscles, was performed primarily for breast reconstruction in the early years. Mostly out of vogue by the 1990s, it is rarely (if ever) performed today. It is often reserved for patients with extremely thin tissues.
- Full coverage: The implant is completely covered by the muscle and fascia, which helps to camouflage the edges of the implant, and thus reduces the appearance of rippling.
- More support: Because the implant is covered by the fascia, the lower pole is better supported. Complete unders serve as an "internal bra."
- Better mammogram readings: Since the muscle and fascia are atop of the implant, technicians are able to get a better reading during mammograms.
- Lower risk of bottoming out: Again, for the reasons mentioned above, bottoming out is less common. Bottoming out means that the breast implants have descended too low on the chest, causing the nipple to be too high on the breast mound.
- Muscle placement: Unlike the pectoralis major muscle that is thick, flexible, and has a large surface area that is detached from deeper structures, the serratus and rectus muscles are thin, taught, inelastic and firmly attached to ribs.
- Intense pain: It is a very painful operation.
- Implant malposition: This is more frequent here than other techniques.
- Capsular contracture: Rates are not superior to subpectoral implant placement.
The Subfascial Position
This is perhaps the newest iteration of implant placement. The implant is placed under the thin translucent veil of tissue called fascia, covering the outer surface of the pectoralis major muscle. Anatomically speaking, it is identical to the subglandular placement, with the exception of the thin fascia. There are no studies that show superiority over subglandular placement in terms of implant palpability, rippling, and rates of capsular contracture.