Sub-Glandular to Sub-Muscular Breast Augmentation

Breast Augmentation

In years past breast implants were commonly placed in these sub glandular (on top of the pectoralis muscle and below the breast tissue) position. This placement of the breast implants tended to allow for less discomfort for the patient given that no manipulation of the pectoralis muscle was necessary.

However, most plastic surgeons agree that placing breast implants in the sub pectoral (sub muscular or dual plane) position does afford some advantages. There tends to be a decreased incidence of capsular contracture (encapsulation), rippling/palpability of breast implants, and interference with mammography and breast implants are placed in the sub pectoral position.

Today, a significant number of patients are presenting with a desire to improve the results of their breast augmentation surgery.   Revision breast surgery can help.  Many of these patients have had their breast implants placed in the sub glandular position and wonder if revisionary surgery is possible replacing breast implants in the sub muscular position. Patients presenting with the desire for breast revision surgery may be concerned with problems such as encapsulation, rippling/probability of breast implants or implant/breast position issues.

In my opinion, replacing breast implants into the sub muscular (dual plane) position can be extremely helpful in improving the results achievable with revisionary breast . For example, for a patient who presents with severe rippling, the pectoralis muscle adds an additional layer of the patient's own tissues between the implants and the overlying skin. I have found that this additional layer is very helpful in improving the look and feel (rippling and palpability of breast implants) of the breasts. Successful repositioning of  the breast implants into a deeper plane often negates the need for use of  (Strattice), a useful material that carries its own potential risks and expenses.

Similarly, replacement of sub glandular breast implants into the submuscular plane may be very helpful for the patient who presents with breast implant encapsulation (capsular contracture). This type of revisionary surgery may help improve the chances that encapsulation will not recur.

I also think that the use of breast implants in the sub muscular position tends to keep the implants sitting higher on the chest wall (over a longer period of time) than implants placed above the pectoralis muscle. Again, patients may present with breasts that they feel are “too low”; revisionary surgery that involves reaugmentation into the submuscular position may be helpful in keeping the breast implants in the higher chest wall position and maintaining longer-term “superior pole fullness”.

One of the main concerns that arises when considering exchanging breast implant positioning from the sub glandular to the sub muscular position involves the management of the overlying breast tissue, skin, and the nipple/areola complexes. Sometimes, depending on the current position of breast and nipple/areola tissue, exchanging breast implant positions does not involve any manipulation of the overlying tissues. However, for many patients adjustment of the overlying skin, breast tissue, and nipple/areola complexes is necessary to achieve the desired results.

For example, if replacing the breast implants into the submuscular position creates an unsatisfactory shape of the breasts (where the breast implants sit relatively high on the chest wall and the breast tissue sits/hangs lower on the chest wall) then breast lifting will likely be necessary to improve the results of surgery. Breast lifting usually involves removal of some lower breast skin and movement of the nipple/areola complexes superiorly. This movement of the “breast mound” superiorly serves to place the breast tissue over the breast implants which are now sitting higher on the chest wall. This creates a situation where the breast implants and the overlying breast tissue are in “harmony” and look/feel like a unified breast unit as opposed to a “double bubble” or “snoopy dog” appearance (where the breast implant sits high on the chest wall and the breast skin/tissue/nipple areola complexes sit lower on the chest wall). 

Of course, breast lifting (if necessary) involves additional incisions/scars which must be explained and accepted by the patient. The scars tend to fade with time and/or scar revision surgery and tend to be well accepted by patients who understand the trade-off involved with breast lifting surgery. This trade-off involves the upside of improved positioning and contour of the breasts in exchange for the down side of the presence of scars (that result after skin excision associated with breast lifting).

It should be noted, that sometimes (despite best efforts) breast implant repositioning to the submuscular position is not possible or is not permanent. Sometimes intraoperatively the surgeon may find that the breast implants will not remain in the sub muscular position tending to want to “slip out” into the sub glandular position. This phenomenon may limit the size of breast implant that can be successfully placed into the sub muscular position.

To conclude, replacement of breast implants into the sub muscular or “dual plane” position may be an excellent option to treat patients who are having problems/complications associated with sub glandular breast implants. I have found that this type of revisionary breast surgery does involve some finesse and a definite learning curve. It would behoove patients seeking this type of surgery to carefully seek board-certified plastic surgery consultants who have had extensive experience with revisionary breast surgery.

Tom Pousti MD

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