When I was in training, every cosmetic surgeon that I worked with put breast implants below the muscle. The teaching was that this would contain the implant, isolate it from the breast, and offer more coverage on the upper portion. I was taught to perform the procedure that way, and continued in practice as one of many surgeons with that same training.
As I evolved in my own practice, I reconsidered many of the things that had been taught to me. Among them was the issue of where to place a breast implant. It had always seemed a bit strange to me that someone would take a device intended to mimic breast and put it where the breast does not exist. Yes, it is true that the muscle is under the breast, and putting an implant under the muscle does succeed in making the breast look bigger, but the breast tissue itself does not actually belong there.
It also occurred to me that the muscle that is used for this purpose, the pectoralis major, normally lies flat on the ribs, tight and immovable. There is no space under this muscle, without cutting, ripping, and stretching it considerably. This same muscle also only covers about two thirds of the breast footprint, and especially after being pulled up to fit a large implant beneath it, it ends up only covering about half of the device anyway. What is more, even when maximally stretched, the muscle has the potential to contract, and this can cause a very socially awkward animation deformity that no one would want to display. The other issue with placement under the muscle is that, predictably, manipulating the muscle like that causes a significant amount of trauma to the area, and this leads to considerable postoperative pain, and longer recovery times. So why has this technique been the approach of choice for generations of surgeons? That is probably multi-factorial.
For one, surgeons like to keep it consistent. Once they are comfortable with a certain technique, it becomes a hard habit to break. Another reason is that, for decades, some of the complications associated with breast implants were attributed to contact with the native breast tissue. Having a barrier between the two was thought to prevent many types of problems, notably capsular contracture. But probably one of the most relevant reasons why this technique has been widely embraced is that, at the time of my training, the teaching was that the most common patient complaint after breast augmentation was that they had not “gone big enough.” As a result, surgeons placed the largest implants possible, and having that tight muscle layer to contain them actually did serve a purpose.
In recent years, trends in breast augmentation have seen a remarkable shift. As I began to appreciate the relevance of placing a breast device in the breast plane itself, and as surgical techniques improved in terms of limiting complications from breast implant contamination with breast bacteria, the under-the-muscle technique has become less argued. That, coupled with recent trends towards natural results and teardrop shapes, has led to a revisiting of the procedures and a fresh perspective.
There are circumstances where I would choose an under-the-muscle approach, such as when there is already a space made there and the patient is not having any issues with it. But on the whole, I prefer to go back to the basics and follow nature’s lead. As an art student and lifelong designer, my ideas and images of ideal forms are based in anatomy rather than habit; and my patients’ experiences dictate my preferences, even if this requires revisiting long-standing patterns. It is only through careful reflection and adaptability that we progress. And sometimes progress means going back to basics.
Yes! Breast implants can look fantastic above the muscle. The key is to have them properly sized and positioned, and to choose the right type of implant for the patient. An oversized implant, or one with an imbalanced profile, will be harder to have sit right without the muscle literally holding it in place. But with the right choices and proportions, a well chosen implant can not only look fantastic above the muscle, but it can also move with the breast and simulate what it is supposed to simulate: more breast!