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Breast Implant Planes (Pockets)

Measuring breast plate thickness

The pocket (placement) position of breast implants has been studied for many years. No single key fits every lock, and no single surgical procedure fits every patient. This holds true for all Plastic surgery procedures. As with many other Plastic surgery procedures, and as common sense would dictate, no single operation fits every patient. If multiple types of operations are available, and the same operation is performed on every patient irrespective of the patients specific anatomical situation, common sense would dictate that some patients will get a suboptimal result. The particular breast augmentation procedure should be chosen based on the patients specific anatomic situation, her goals and preferences, and because there is wide variation in breast shape and breast size one operation does not fit all patients.

Sub-Glandular Procedure

The sub-glandular breast implant procedure is generally reserved for patients with a thick breast gland. In this procedure, the implant is placed between the breast gland and the chest muscle. The sub-glandular breast implant procedure has advantages in very active patients, especially those that participate in strenuous activities with the upper extremities, such as weight lifting.

The sub-glandular procedure (above the chest muscle) was the most commonly performed procedure thirty years ago. In this operation the breast implant is placed below the breast gland and above the chest muscles (pectoralis major muscle). The sub-glandular (above the chest muscle) procedure does not injure the pectoralis major (chest) muscle which is one of the largest muscles in the body. One study showed that partially sub-muscular (partially under the muscle) placement of breast implants resulted in a 20% loss of torque strength. Although the study was in breast cancer patients, inference (and common sense) for the cosmetic breast augmentation patient is strong. Common sense would indicate that if you (partially) cut a muscle the strength may decrease. Muscular action directly on the implant can be an advantage, and it can also be a disadvantage. One advantage of the sub-glandular (above the muscle) procedure is that there is no muscular activity directly on the implant. As a result, it is less likely that the breast implant will be displaced to an unfavorable position over time. In other words, with sub-glandular implant placement, it is more likely that the breast implant will remain in the same position that it was placed at the time of surgery. The potential disadvantage of the sub-glandular (above the chest muscle) procedure is the lack of muscular action that is thought to reduce problematic capsular contracture (breast firmness). If the breast implants are placed in the sub-glandular (above the muscle) pocket, the external massage can be performed by the patient as a substitute.

Partially Sub-Muscular Procedure

The sub-muscular procedure is more accurately called the “partially” sub-muscular procedure. The sub-muscular procedure is generally reserved for patients with a thin breast gland. In this procedure, the implant is placed between the chest muscle and the chest wall, and the implant is covered on the upper surface by muscle. This procedure has advantages in patients that have a very thin breast gland by placing more “soft tissue” over the top of the breast implant.

The Procedure

The partially sub-muscular (below the chest muscle) procedure places the breast implants partially under the chest (pectoralis major) muscle. The partially sub-muscular (below the chest muscle) procedure has been a source of confusion due to the often used terminology “under the muscle procedure”. The breast implants are placed under the muscle in this procedure, but only (approximately) the upper one half of the implant is covered by muscle (plus breast gland), and (approximately) one half of the lower breast is covered only by breast (gland) tissue. In other words, in the lower half (approximately) of the partially sub-muscular procedure the anatomic relationship is the same as the sub-glandular (above the muscle procedure). This procedure is more accurately called the partially sub-muscular (partially below the chest muscle) procedure to prevent confusion with the totally sub-muscular breast augmentation procedure. The partially sub-muscular (below the chest muscle) procedure by definition injures the pectoralis major (chest) muscle. Some surgeons feel that intentionally injuring a a very large normal muscle which could obviously affect its function (strength, range of motion, endurance) for an elective cosmetic surgery should not be taken lightly. As noted previously, one study confirmed this concern and showed a 20% torque strength loss. Common sense dictates that if injuring a large normally functioning muscle (pectoralis (chest) major) can be avoided by choosing another equally effective procedure, this may be the most prudent option. Because the pectoralis major (chest) muscle is injured (cut and or cauterized) during the partially sub-muscular (below the chest muscle) procedure, the recovery period is longer (6-8 weeks as compared to 1-2 weeks) when compared to the sub-glandular (above the muscle) procedure.

Advantages and Disadvantages

There are thought to be some advantages to the partially sub-muscular (below the chest muscle) procedure. In the partially sub-muscular (below the chest muscle) procedure, there is more natural soft tissue (breast gland and muscle) covering of the breast implant in the upper part of the breast compared to the sub-glandular (above the muscle) procedure. This gives a more natural appearance in the upper pole of the breast in thin patients (see the “pinch test” in subsequent section). Because the implant is below the pectoralis (chest) muscle, any contraction (flexion) of that muscle with arm movement will act directly on the implant. Because there is no muscle on (approximately) the lower half of the implant with the partially sub-muscular (below the chest muscle) procedure, there is no dynamic (active) resistance on the bottom half of the breast (no muscle coverage), and the implant can be displaced in that direction (down and outside). If this happens the implant can be malpositioned (in the wrong place). This unfavorable displacement of the breast implant can also cause asymmetry if one implant displaces more than the opposite side. It is thought that muscular action with the partially sub-muscular (below the chest muscle) procedure may reduce the chances of problematic capsule formation that results in increased breast firmness which is an advantage. As noted earlier, the muscular action with the partially sub-muscular (below the chest muscle) procedure also has a tendency to push the breast implants out from under the muscle to an anatomically unfavorable position. In some patients, the implant movement (displacement) is inconsequential, and in other patients the displacement may require additional surgery. Implant displacement is more likely to occur in extremely active patients and especially in weight lifters. Problematic implant displacement is also more likely to occur in extremely thin patients or that have a paucity of tissue or poor tissue integrity in the bottom outside area of the breast (next to the elbow when the arms are hanging in a standing position). This condition can be developmental or from aging, or from pregnancy. Severe implant displacement may require additional surgery called a capsulorrhaphy, which adjusts the capsule around the breast implant. Another problem with the partially sub-muscular (below the chest muscle) procedure is the so called “jumping breast” phenomenon. In some cases, when a patient that has had the partially sub-muscular (below the chest muscle) procedure moves her arms or flexes the pectoralis major (chest) muscle, the breast implants appear to “jump”. This can be very disconcerting to some patients. In addition, with this muscular action, the upper pole (top half) of the breast flattens and can ripple. This is a very unnatural appearance that commonly occurs with the partially sub-muscular (below the chest muscle) procedure when the chest muscle (pectoralis major) is flexed with arm movement, especially when wearing a low cut garment such as a evening gown or a bathing suit.
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Completely Sub-Mascular Procedure

The completely sub-muscular procedure is different from the partially sub-muscular breast implant procedure in that the entire breast implant is covered with muscle, both on the top and the bottom. In the completely sub-muscular breast implant procedure the implant is placed between the chest muscles and the chest wall. The completely sub-muscular breast implant procedure is an option in patients with very thin breast glands or in the patients that have weak breast tissue on the lower outer area of the breast. The completely sub-muscular procedure gives muscle support and increased “soft tissue” over the entire breast implant which is helpful in these patients.

Advantages and Disadvantages

The totally sub-muscular breast implant procedure is another option for breast implant placement. The totally sub-muscular procedure places the breast implants completely under a layer of muscle. The pectoralis major (chest) muscle is not large enough to cover the entire breast implant, so other muscles must be used to achieve coverage of the entire implant. These muscles are the serratus (over the lower ribs) muscle and the rectus abdominis muscle (sit up muscle). The advantage of the totally sub-muscular breast implant procedure is more natural soft tissue over the entire breast implant, which in this procedure, covers the top and the bottom of the breast implant. In the totally sub-muscular procedure, the entire implant is covered with breast tissue and muscle. This type of procedure may be chosen in patients with extremely small breasts and/or poor breast tissue integrity. Similar to the partially sub-muscular (below the chest muscle) procedure, normal muscles are injured with this procedure, except with this procedure three muscles are injured as compared to the partially sub-muscular breast implant procedure which injures only one muscle. Because there is extra support on the bottom of the breast (serratus muscle and rectus abdominis muscle) unlike the partially sub-muscular (below the chest muscle) procedure and the sub-glandular procedure (above the chest muscle) which have none, it is less likely that the implant will displace with muscular action (movement of the arm). Because the breast implant is covered with muscle on the bottom of the breast with the totally sub-muscular breast implant procedure (pectoralis major muscle on the top, and serratus muscle and rectus abdominis muscle on the bottom) it follows that there is also muscular action on the bottom of the breast. Because there is muscular action and muscle tone on the bottom one half (approximately) of the breast that covers the breast implant, there is a tendency to flatten the bottom half of the implant more than the sub-muscular breast implant procedure and the totally sub-muscular breast implant procedure. This area of the breast is normally rounded, full, and not flat, so less fullness in this area is a little less natural looking. This is an acceptable compromise when compared to severe breast implant displacement that can occur in extremely thin patients, extremely active patients, or patients with compromised tissue integrity.

Sub-Fascial Procedure

The sub-fascial breast implant procedure is another choice for pocket placement. In the sub-fascial breast implant procedure, the implant pocket is created below the muscle fascia (outer connective tissue wrapping of the pectoralis major (chest) muscle, the serratus muscle, and the rectus abdominis muscle) and above the muscle itself. The breast pocket created for the breast implant is below the breast gland and the muscle fascia (connective tissue) but above the muscle layer itself. In other words, the sub-fascial pocket is intermediate in depth between the sub-glandular (above the muscle pocket) and the sub-muscular (below or partially below the muscle pocket). In the sub-fascial procedure, the upper half of the breast implant is covered with breast tissue and pectoralis major fascia. In theory, the sub-fascial breast implant procedure gives more soft tissue coverage than the sub-glandular (above the muscle) procedure without the previously noted disadvantages of the sub-muscular pocket placement (totally below the muscle pocket or partially below the muscle pocket).

Dual Plane Procedure

The dual plane breast implant procedure is a sub-type of the partially sub-muscular breast implant procedure. This procedure creates a space above and below the chest muscle, which is different from the sub-glandular breast implant procedure and the sub-muscular breast implant procedure. This procedure may be an option in patients with thin breast glands, no breast sagging, and very mobile breast glands. This procedure allows the chest muscle to move upward, which has advantages in this type of breast. The dual plane breast implant procedure may also be an option in patients with thin breast glands, minimal breast sagging, and a constricted (tight) lower breast. In this situation the procedure allows the chest muscle to move upward, which has advantages in this type of breast to help fill out the bottom of the breast.

The Procedure

The dual plane procedure is a subtype of the partially sub-muscular (below the chest muscle) procedure. The dual plane procedure creates pockets (planes or spaces) above and below the pectoralis (chest) which allow the muscle to translate (slide) in relation to the breast gland. The dual plane procedure can be used for patients with ptosis (sagging) and patients with a constricted lower breast pole (breast is too small at the bottom). Three different types of dual plane procedures have been described based on variations in anatomy. The utility of this procedure is that it allows a better result with breast augmentation with a single operation in the patient with a specific anatomic problem. The anatomic situations that are treated with this procedure previously may have required two separate procedures or more.

Determining Candidacy

All of the pocket placement recommendations and choices are affected by an individual’s anatomic variation. Anatomic differences are the basis of choices of procedures and types of breast implants. Anatomic variation can occur as a result of developmental changes, weight loss or weight gain, pregnancy, or the aging process. The specific anatomic variation dictates which procedure is best to some degree. One anatomic finding that helps determine which operation is best is the “pinch test”. The “pinch test” helps determine the thickness of the natural breast tissue (breast plate). The “pinch test” is performed by pinching the breast tissue above and below the nipple-areolar complex and measuring or estimating the breast (plate) thickness. In general, if the breast (plate) is thicker then there is less concern about the amount of soft tissue covering the breast implant. There is no hard and fast rule in determining “thick” versus “thin” breast tissue, however, it is generally accepted that a 2 centimeter breast (plate) thickness found on the “pinch test” is the dividing point in determining which procedure to choose. If the natural breast (plate) thickness is greater than 2 centimeters then a sub-glandular (above the muscle) procedure may be the best pocket choice with many other factors considered. If the natural breast (plate) thickness is less then 2 centimeters then a partially sub-muscular (below the muscle) procedure, or a totally below the muscle procedure, or a sub-fascial procedure may be the best pocket choice with many other factors considered. This is not to imply that a 1.9 cm (centimeter) breast (plate) thickness should be done one way and a 2.1 cm (centimeter) breast (plate) thickness should be done another way. There are many other factors that help determine which pocket choice is best for each individual patient in addition to the “pinch test”. These include, but are not limited to, integrity of the breast skin, integrity of the breast gland, breast sagging, base diameter of the breast (widest diameter of the breasts), breast symmetry (breasts mostly match) or breast asymmetry (breasts do not match), chest wall shape, size of the breast implant chosen, patient’s activity goals and patterns, and most importantly, the patients preference after a thorough informed consent. Again, there are no hard and fast rules about the choice of breast pockets but the “pinch test” does offer some general guidance. There is nothing permanent about the location of the breast implant pocket. If a patient chooses a breast procedure (pocket) and later decides that a different pocket is desired for whatever reason, then the breast implants can be moved from one position to the other. In other words, breast implants can be changed from a sub-muscular pocket to a sub-glandular pocket, or vice versa. All these options (and more) will be discussed in detail with you at your consultation.