Breast augmentation with implants has been the most popular surgical procedure I have performed since the beginning of my practice in 1973. It continues to remain so. However, we have been through some trying times since the 70’s.
The government took silicone implants off the market for 14 years because of silicone rupture and alleged reactions to the free silicone. The good news, however, has been the improvement in the implant quality. The old silicone was more of a liquid than today’s “Memory Gel,” which will not leak out even if the bag ruptures. Also before we had what was called “implant bleed.” This meant that the silicone leaked through the bag enough to leave silicone on the surface of the implant.
Saline implants were then used exclusively when the silicone implants were taken off the market. Saline implants were and still are good implants. Their problem is that they feel like a bag of water, which is what they are, and this is like comparing a water bed to a Tempurpedic mattress. They just don’t feel the same as a real breast, and a silicone implant does. However, if a patient has a B cup or adequate breast tissue to cover the implant, it feels OK. Remember that the implant goes behind the breast or muscle. Saline implants also should be placed behind the muscle in most cases because one can often feel wrinkles in them. The muscle hides this in most cases.
Now we have the question of whether the implant should be behind or in front of the muscle (often referred to as submuscular or subglandular). There are pros and cons to both positions. If there was one perfect way, there would not be an alternative.
The advantages in front of the muscle are:
- You can get them closer together for a better cleavage in many cases
- Implants do not move or flatten out when the pectoral muscle is contracted
- The recovery time is less painful and is shorter.
The disadvantages of in front of the muscle are:
- The encapsulation rate may be slightly higher. This is when the adjacent breast tissue tightens on the implant making the implant feel firm.
- A mammogram may be harder to interpret.
The advantages of the sub-muscular position are:
- Possibly lower encapsulation rate
- Less wrinkles with the saline implants
- A mammogram can be more easily read
If a patient has minimal breast tissue, I use the submuscular position so the edge of the implant cannot be seen.
Some plastic surgeons use entirely one technique and others tailor the technique to the patient. I feel each patient should be assessed individually and the various advantages and disadvantages discussed with the patient. Everyone is different and surgery should be individualized.