Breast Implant Surgery

• Placement
• Incisions

Placement

The implant can either be placed under the breast (subglandular) or under the pectoral muscle (sub-pectoral).

Size of the submuscular implant (shown as circle) in relation to the contralateral breast. This illustrates the necessity of mobilizing the four muscles in the problem area.

Another special technique is called “dual plane” where the implants are placed half under and half in front of the muscle. A fourth technique is sub-fascial, behind the fascia covering the muscle.

	Breast before augmentation	Breast after subglandular augmentation	Breast after submuscular augmentation

Generally, in the thinner patient with smaller breasts, the recommendation would be sub-pectoral. The implant would look more natural and the edges would not be palpable.

When there is more breast tissue that has a degree of sag an implant placed under the breast would give a greater degree of lift. If the implant is placed behind the muscle, the breast tissue may still hang down away from the implant, the so-called “snoopy effect”.

If the nipple-areolar complex is below the intra-mammaryline (i.e. 2nd degree and 3rd degree ptosis) an uplift operation (mastopexy) will be required. Augmentation and mastopexy can be performed together or separately. Separately is recommended to prevent widening of the scars– but most women request one operation and accept this possibility. Scars can be revised later.

A dual plane technique is occasionally recommended when there is a small degree of breast sag with thin, stretched tissue at the upperpole.

Incisions

There are four possible incisions through which an implant can be inserted. The most common one is in the fold of the breast (infra-mammary). As saline implants are inserted empty and then filled, a smaller incision, about 3cms, is needed. The size of the incision for silicone implants depends on the size of the implant, ranging from 4.5 to 6.5cms. With time this will fade into a thin white line and hardly be visible in the infra-mammary fold. This is the most direct approach that enables the creation of a precise implant pocket.

Peri-areola

The peri-areolar incision, also leaves a fairly inconspicuous scar if this is placed precisely on the areola margin. This incision is used when a mastopexy needed, the areola is large or the infra-mammary fold is high. Some breast tissue is traversed and may create some scarring in the breast, but this is rarely a problem clinically or radiographically. If there is little breast tissue, this approach gives a direct approach to the implant pocket allowing for easier and more accurate dissection in all directions.

Trans-axillary

A trans-axillary approach leaves no scars visible on the breast and will only be seen with the arms lifted up. The implant is placed in the sub-pectoral position. Care needs to be taken not to enlarge the pocket too much superiorly to limit upward migration and the infra-mammary fold levels need to be equal to prevent asymmetry post-operatively. This is also now performed endoscopically. This has improved the technical accuracy and is associated with less implant malposition.

Umbilical

The umbilical approach seems too far away for any accurate dissection