Insertion of a breast implant under the muscle: what is important for the surgeon to know. Rating of the best plastic surgeons and clinics How breast implants are inserted

One of the most controversial issues in plastic surgery: when breast augmentation, implants should be placed under the gland or under the muscle?

History of mammoplasty

The breast augmentation described in the literature was undertaken at the very beginning of the 19th century. In this case, the increasing substance was always located under the gland. Since then, various materials have been tried for breast augmentation from ivory, ebony to paraffin, and of course, all were rejected. In the 1950s, foam sponges were tried for breast augmentation. Although the material was biocompatible, the connective tissue grew into the sponge, making it very hard. Mammoplasty began in earnest in the mid-1960s, when silicone implants began to be used for breast augmentation (Cronin and Gerow, 1964). Again, the implants were placed under the gland.

The main problem with implants was the formation of a hard breast after breast augmentation surgery. The implants themselves did not become hard after plastic surgery - the problem is that the human body perceives the implant as a foreign body. Since the body cannot get rid of it, a protective mechanism is activated: a barrier layer is formed around the implant - a shell consisting of connective (scar) tissue. It is commonly referred to as a capsule. If the capsule begins to contract around the implant, it tends to become spherical and feels like a solid object. This condition is called capsular contracture. Why some patients develop capsular contracture after mammoplasty remains a mystery. An even bigger mystery is the fact that this complication after breast augmentation often occurs in only one of the two breasts.

The first silicone implants for breast augmentation had a base made of dacron, which was supposed to help fix the implant in place of its installation. But within a few years it became clear that dacron causes a violent reaction of the tissues and leads to the most pronounced cicatricial contracture. In the late 1960s, breast augmentation was performed for the first time, placing an implant under the muscle. Axillary mammoplasty quickly gained popularity due to the belief that in this case the breasts will be softer. Unfortunately, the degree of breast hardness is difficult to quantify. Although there is a generally accepted Baker classification of cicatricial contracture of the breast, the definition of its degree remains subjective. Also, the ways of solving cicatricial contracture after breast augmentation have not been determined.

Arguments for axillary mammoplasty

The muscle covers the implant, and thus any capsular contracture is less detectable.
For the same reason, contouring of implants is less noticeable.
More accurate mammography results.
In women with "absent" breasts, the edge (contour) of the mammoplasty implant is less visible.
Mammoplasty takes less time.

Arguments for subglandular mammoplasty

It is quite obvious that the breast is above the muscle, and the implant is designed to increase the breast.
For this reason, placing the implant under the gland looks more natural.
Since the muscle covers half, or even a third of the implant, we can only talk about the minimal advantage of axillary mammoplasty.
Accordingly, most of the implant is not covered by muscle, which in practice only slightly reduces the likelihood of capsular contracture.
Axillary mammoplasty requires the dissection of muscle fibers. Because of this, as well as the pressure of the underlying implant, the pectoral muscle becomes significantly thinner (atrophies). In fact, the muscle atrophies, causing a decrease in the volume of the upper pole of the chest.
In the presence of ptosis, subglandular mammoplasty lifts the breast much better.
A correctly performed mammogram is reliable in 95% of cases. MRI is 100% effective and will eventually become the standard for diagnosing breast diseases.
With the subglandular location of the implant, the risk of postoperative bleeding is lower.
Significantly less postoperative pain after breast augmentation.
Breast augmentation can be performed under local anesthesia with intravenous sedation, which is safer.

However, 50-60% of surgeons perform axillary mammoplasty.

Consultation with a plastic surgeon

Dedicate the doctor to the motives that forced you to have breast augmentation surgery, and what you expect from mammoplasty. Never increase your breasts in order to please your partner, otherwise you may be disappointed. Be clear about whether you want big breasts or natural breasts.

Notice the lack of symmetry. You may not notice that you have a different volume of the left and right breasts, that the nipples are at different levels, etc., and after mammoplasty it is unreasonable to blame the doctor.

Pay attention to stretch marks - after breast augmentation they will become larger.

With severe ptosis (breast prolapse), only mammoplasty may not be effective and mastopexy will be required.

Relevant anatomy of the chest

The female breast covers the anterior chest wall from above from the level of the second rib to the fourth or fifth rib from below. Its upper half lies above the pectoralis major muscle, the lower half lies half above the serratus muscle and axillary fascia.

The mammary glands are essentially an organ of the skin. It is intimately fused to the skin by supporting ligaments (Cooper's ligaments). This is because the skin and mammary glands developed from the same germ layer. Therefore, there is a natural layer between the gland and the muscle, which makes it easy to create a cavity for the implant.
The chest is supplied with blood from the branches of the axillary artery, intercostal arteries and internal mammary artery. Few blood vessels enter the gland from its base. The innervation of the chest comes from the anterior and lateral cutaneous branches of the 4-5-6 thoracic nerves.

Contraindications for subglandular mammoplasty

There is one absolute contraindication to subglandular mammoplasty - the condition after radiation therapy.

Another reason that requires axillary mammoplasty is the thinning of the tissues of the gland, which can occur after pregnancy.

"Small" breasts can be considered as an indication for axillary plastic surgery only as a result of the more difficult performance of mammography in the future.

One of the main factors determining the quality and durability of the result of the most popular plastic surgery today (breast augmentation) is correct choice of the anatomical layer for the silicone implant to be installed.

Of course, a large number of factors are first determined to decide which of the four options is optimal.

On what factors does this choice primarily depend?

position of the mammary glands on the chest wall. It can be innately high, medium and low;
the presence or absence of acquired mastoptosis (omission of the mammary glands), its degree;
characteristics of the skin and subcutaneous tissue: thickness, elasticity, presence or absence of stretch marks;
severity (thickness, area, elasticity, anatomical features) of the pectoralis major muscles;
the presence of deformity of the sternum and ribs.

under the gland

Under the fascia

In 2 planes

under the muscle

So, what are the main points that the surgeon, and the patient, should take into account when they decide to install an implant under the muscle during breast augmentation:

This method can be used in all cases where the patient has intact pectoralis major muscles;
This method cannot be used in the presence of ptosis (omission) of the breast, if this problem is not solved surgically (endolift or breast lift);
Both the surgeon and the patient must know from the outset that a good long-term result is always achievable, but the rehabilitation period in some cases can be extended, sometimes twice. That is, if after other options the desired result comes after 1 month, then here after 2. And for this you will need to do a special exercise 8 minutes a day;
When choosing implants, there is no point in using anatomic teardrop implants (except in special cases). Otherwise, the very shape of the implants will impede rapid rehabilitation;
It is categorically NOT possible to use fixed implants (macrotextured or polyurethane). This may cause some problems.

Over 20 years of placing an implant under the muscle in more than 1000 patients, in all cases a good long-term result has been obtained. All patients who previously had experience of wearing implants under the gland or in two planes noted that after surgery using a full myofascial pocket, they began to feel more secure. Most of the patients generally ceased to feel the implants as something separate, constantly reminding of themselves. See

To increase the size of the mammary glands, specially selected implants are used, which can be installed in various zones: under the fascia, under the gland itself, in two planes, in the axillary region, and also under the muscle. Each method has its advantages and disadvantages, but the plastic surgeon always selects it, guided by an individual approach.

As you know, natural breasts always have a smooth, gentle slope that descends to the nipple area. The main volume is located in the lower zone of the breast, while the area of localization of the nipple is the most protruding. It is believed that if you install a breast implant under the muscle, the result after the operation will look exactly like this.

Also, experts highlight another important advantage of this method - reducing the risk of complications such as capsular contracture. Installing an implant under the muscle makes it possible to improve the coverage of the upper slope, while the endoprosthesis installed in this way does not interfere with mammography and ultrasound diagnostics.

It should be remembered that the initial state of the mammary gland tissues and size must be taken into account by the surgeon when choosing an implant. It is recommended to install it under the muscle or under the gland only with pronounced glandular tissues. If a girl has a zero breast size, then, most likely, experts will advise her another method.

If the patient has a desire to create a "Hollywood" breast shape, which is characterized by a pronounced upper pole.
If the woman's original breast size is greater than zero.
If the patient has large pectoral muscles that have not been traumatized before.
If signs of mastoptosis are observed (in this case, the method can be used in combination with a breast lift).
If the patient plans to install round-shaped implants. Teardrop-shaped endoprostheses are usually not recommended for submuscular placement.

For comparison, it is worth looking at what the breast looks like if an implant was installed under the muscle (photo with examples of different options):

Methods for installing an implant under the pectoral muscle

The plastic surgeon determines how to place the implant under the muscle, what type of endoprosthesis to use and what size to choose. It is based on the patient's preferences, her wishes for a new breast shape, and also necessarily takes into account all the anatomical features of her body, the proportions of the figure, so that everything looks harmonious and proportionate after the operation.

This is very important for obtaining a natural result of breast augmentation. If implants are placed under the pectoral muscles, the surgeon should understand which method of their placement will be better in a particular individual case.

Submuscular location of the implant

This is a method in which the implant is placed under the pectoralis major muscle. In this case, the lower pole is supported by the fascia of the serratus muscle. Many surgeons call the submuscular location of the implant a way to create a "Hollywood" shape of the mammary glands with the most pronounced and voluminous upper slope. Another distinctive feature of the method is the absence of the need to cut the lower part of the muscle.

Subpectoral (or biplanar) implant placement

The method implies only its partial placement under the muscle. The upper part of the endoprosthesis is located under the muscle, the lower part is above the muscle. This installation of the implant under the pectoral muscle is very popular in the United States. It is believed that the subpectoral method allows you to get a more natural result of breast augmentation without the risk of contouring the implant.

How is the implant placed under the muscle?

The main stages of plastic surgery:

The use of anesthesia and the opening of surgical access.
Formation of a pocket under the muscle or partially under the muscle and gland, where the implant will subsequently be located.
Installation of the implant under the muscle or gland in the formed pocket.
The imposition of surgical sutures.

What does the breast look like if the implants are placed under the pectoral muscles?

Experts warn that placing an implant under a muscle or under a gland allows you to get a “Hollywood” breast shape, which is characterized by the following external features:

a pronounced upper slope, due to which it visually seems even more voluminous;
high position of the chest;
the mammary glands are visually larger than the chest;
the possibility of contouring the implant with a submuscular location (it is recommended to place endoprostheses partially under the muscle, then there will be no such effect).

What does the breast look like if the patient had an implant installed under the pectoral muscle (photo with real examples):

Benefits of placing an implant under the muscle

Improved coverage of the upper slope. It becomes more pronounced and voluminous.
Almost complete elimination of the risk of developing capsular contracture, a postoperative complication that is possible after the installation of the implant in other ways.
Natural breast result with the right choice of implants.
No risk of endoprosthesis sagging, which is sometimes possible with other installation methods.
Impossibility of palpation of the implant: its edges are invisible from the inner and upper borders.
No problems with mammography: Implants do not complicate the diagnosis in this arrangement.

Disadvantages of installing an implant under the muscle

Sometimes, after placing an implant under the muscle, the lower breast area may look unnatural when the implant is located above the lower fold of the gland.
The breast will look much larger than the chest if the endoprosthesis is too large. If you have chosen a submuscular implant location, it is recommended to opt for smaller sizes.
An implant under the muscle should not be installed if a woman is engaged in active sports, since ripples of the endoprosthesis may occur during exercise, which will look unnatural and strange.

The decision about the need for mammoplasty in most women is motivated primarily by the desire to increase breast size. An important point is the choice of one form or another of the breast. But the outlines of the future breast depend not only on the type of implant, but also on the method of its installation.

How does the shape of the implants affect the appearance of the breast?

To understand this, you need to know that a woman's breasts and implants interact with each other, put pressure on each other. The mammary glands already have their own specific shape, and the degree of natural softness and elasticity differs from the same characteristics in breast endoprostheses. All these indicators affect the appearance of enlarged breasts. However, not only the type of implant and the natural shape of a woman's breasts determine the future result. An important role is also played by the choice of the implant installation method: over the pectoral muscle, over the mammary gland. Only experienced surgeons can put all these factors together and predict the final appearance of the operated breast.

Implant placement methods

Submuscular (installation of implants under the pectoral muscle);
Subglandular (installation of implants under the mammary gland);
Subfascially (installation of implants under the fascia of the pectoralis major muscle).

Let's analyze the features of each location of the implants.

Method of installation under the mammary gland

The recovery period when installed under the gland is easier and faster

This method is not very suitable for women with small breast volume. The implant will be palpable and can be seen visually. But the main disadvantage of this method is the possibility of complications in the form of fibrous capsular contracture and loss of nipple sensitivity. But besides the disadvantages, this method also has advantages.

Advantages:

The pectoralis major muscle is not affected, as a result of which the recovery period is reduced, which passes with minor pain sensations or with their complete absence. Edema is also minimal, the mammary glands take their final shape in a short time;
Under physical load, the implant installed in this way is not deformed or displaced;
The subglandular way makes the breast fuller.

Flaws:

Possible capsular contracture;
With thin breast skin, a small amount of adipose tissue and a lack of mammary glands, implants can be seen and felt;
Irregularities in the form of ripples and waves may appear on the skin around the implant;
Due to the lack of muscle support, large implants can stretch the skin and make the breasts sag;
The risk of infection and disappearance of sensitivity is higher;
The appearance of stretch marks on the chest;
Difficulty in blood supply;
Perhaps the appearance of breast asymmetry.

Installation of implants under the gland is well suited for trained women

Plastic surgeons do not often choose the over-muscle method, but it may be ideal for women who have enough breast volume to cover implants, have ptosis but do not want to undergo a facelift, have scarring or dystrophy of the pectoral muscle, have strong muscles due to weightlifting or bodybuilding (trained pectoral muscles can distort the implant).

Valery Yakimets comments:

Leading plastic surgeon, candidate of medical sciences, doctor of the highest category, full member of the OPREH.

There is no perfect way to increase breasts. Each installation method has its own advantages and disadvantages. For example, when implants are placed under the muscle during its tension, the shape of the breast may be slightly distorted. In the case of installation under the gland during physical exertion, the shape will be more natural. But the implants put pressure on the mammary glands from the inside, they become thinner and atrophy, and the implants can be deformed. If a breast augmentation under the gland is performed on a female athlete, then the implant will most likely be visible.

Installation method under the pectoralis major muscle

With a submuscular arrangement of implants, they are completely covered with muscles. This method at one time became an alternative to the subglandular. However, this method also has a sufficient number of significant drawbacks: increased trauma, a difficult recovery period, with a load on the pectoral muscle, the chest can be distorted and deformed. If the implants are incorrectly placed under the pectoral muscle, they can subsequently move.

Advantages:

The implant is completely covered with muscle (this is suitable for women with breast deficiency);
The implant subsequently remains absolutely invisible and imperceptible;
Minimal risk of capsular contracture.

Flaws:

Not the most natural result;
The density of the muscles covering the implants does not allow to achieve the desired size and height of the breast;
Deformation and (or) displacement of implants during contraction of the pectoral muscle.

Plastic surgeons do not often use this installation method in their practice.

Method of installation under the fascia of the pectoralis major muscle

The method of installing the implant under the fascia of the pectoral muscle is considered by surgeons to be the most optimal

Imperfections in the installation of implants by the above methods led to the emergence of an optimal method. Complete coverage of the implant without the risk of deforming the mammary glands has become possible with the subfascial method. Fascia is a well-defined layer, a soft layer between the implant and the skin, under which the edges of the implants will not be visible and the pectoralis major muscle will not be injured. The fascia firmly holds the endoprosthesis.

When placing the implant along the fascia, the breast will not be distorted during contractions of the pectoral muscle. Displacement of implants is also virtually eliminated. When installing implants using the subfacial method, the result is natural and harmonious. The fascia helps to increase the elasticity of the covering tissue and reduces the visibility of the edges of the implants.

The subfascial method is used for breast augmentation with various accesses:

Axillary;
Subglandular;
Periareolar.

It is this method that most specialists use with augmentation mammoplasty.

Advantages:

The most natural look, the transition of the breast is smooth and smooth;
Reduces the risk of developing capsular contracture;
The fascia supports the implants and prevents them from sagging;
There is almost no risk of deformation of the implants during physical exertion.

Flaws:

Postoperative pain;
Long recovery period;
Displacement of the implant over time (with loose breast skin).

Currently, plastic surgeons use fairly gentle, non-traumatic methods and materials that have a lifetime guarantee. This suggests that the installed breast implants are guaranteed to be safe for the body for a long period of time.

Implants can be placed:

1. Installation of an implant under the gland (subglandular location)

The implant pocket is formed under the tissues of the mammary gland between the gland itself and the pectoralis major muscle.

This method of placing endoprostheses is technically the simplest. This method is less traumatic, technically simple to perform, and the least painful for the patient. Due to this, the rehabilitation period is not accompanied by significant pain, the primary recovery period takes 10-20 days.

However, the installation of an implant under the mammary gland is often accompanied by contouring of the implant, that is, its visualization (often patients say the breast is like a ball), stretching of the tissues in the future and sagging of the breast under the weight of the implant itself. In addition, the risk of capsular contracture with submammary implant placement is slightly higher.

So, let's summarize the pros and cons of submammary placement of breast implants.

technical simplicity of the operation
slight pain in the postoperative period
relatively fast recovery
breasts are softer and more mobile
no restrictions on sports

the possibility of contouring or visualization of the edges of the implant
a high probability of overstretching of the breast tissues under the influence of the mass of the implant, which can eventually lead to sagging of the breast
excessive mobility of the implants, which can lead to the displacement of the implants to the sides in the prone position
slightly higher chance of capsular contracture

Who is eligible for a breast implant?

Most often, this method of surgery is suitable for nulliparous women with well-defined soft tissues, the thickness of which is at least 1.5 cm. At the same time, the soft tissues of the breast must be elastic, and the gland itself must be at least 50% represented by the actual tissue of the breast.

Who is not suitable for a breast implant?

It is not suitable for patients with thin breast soft tissues, with a large number of stretch marks, flabby skin, as well as for those whose breast thickness is less than 1.5 cm and is mainly represented by adipose tissue.

2. Placement of a breast implant under the muscle (subpectoral location)

The essence of this method of breast augmentation lies in the fact that the implant pocket is formed under the pectoralis major muscle, which lies on the chest wall and is located behind the mammary gland. To do this, the surgeon partially dissects the lower part of the pectoralis major muscle.

This method of installing breast endoprostheses is more complex from a surgical point of view and requires the surgeon to be careful and careful with the soft tissues of the breast.

Since the pectoral muscle contains a large number of nerve endings, the patient experiences significant pain in the postoperative period, which requires adequate anesthesia.

However, despite the disadvantages of the early postoperative period, this method of breast augmentation has a number of significant advantages, which makes it the most popular, and in some cases the only possible way to perform mammoplasty. Consider its pros and cons.

the ability to install implants even in very thin patients with severely thinned breast soft tissues
lack of contouring (visualization) of implants, even in women with soft breast tissue deficiency
better fixation of implants in the implant pocket, less chance of displacement of implants under the influence of gravity
low probability of sagging of the mammary glands due to the weight of the implants
no effect of "spreading" or displacement of the implants to the sides in the supine position
less likely to develop capsular contracture

a technically more complex operation that requires more attention and accuracy from the surgeon.
more pronounced pain in the early postoperative period
longer recovery period

Who is suitable for pectoralis major implants?

Who is not suitable for implant placement under the pectoralis major muscle?

There are no unambiguous contraindications to this method of surgery, but surgeons believe that if the patient's soft tissue characteristics are such that they can securely fix the implants in the desired position, mask its presence well, then you should not disturb the muscle, in this case it is better to install the implants under the iron The pectoralis major muscle will come in handy later, for example, during a second operation in a few years.

The decision on how to perform the operation should be made by the surgeon, the patient, in turn, should be familiar with the plan of the operation and the arguments that the surgeon is guided by when choosing a method of breast augmentation.