Why avoiding muscle coverage in augmentation mammoplasties results in fewer long term complications

As a plastic surgeon who trained in the late 1990’s and who has been in practice eighteen+ years I have witnessed many changes and evolutions in breast augmentation surgery.  As I started my practice we were only afforded the use of saline implants for our cosmetic patients. These devices yielded less than satisfying results due to rippling, a very stereotypical augmented round shaped breast. The saline filled plastic bags demanded that the surgeon place the implants partially under the muscle to soften the outline and attempt to hide the rippled appearance of the implant.  However, the outer edges of the breast could not be covered by the chest muscle and still showed the underlying implant.   Additionally, the visual results were pleasing at first but, over time, the constant chest muscle contraction overtop of the smooth round saline implant resulted in compressing the water inferior and laterally similar to a water hammer affect. The net result over many years is an over-expanded pocket that becomes larger than the implant and, in a reclined position, the device falls off the chest wall and into the armpit resulting in widely displaced implants and breasts without cleavage.  Additionally, a less than desirable appearance occurred when a woman bent forward and the weight of the implant, combined with the over-stretched skin of the upper pole resulted in significant pleating of the saline implant.

Today I do not offer saline implants to my patients because I feel the results are so inferior compared to silicone gel devices. I was trained originally in the nineties to perform mostly a blunt dissection of the muscle off the chest wall and create larger pocket sizes than the implant. The modern surgical approach utilizes finesse with meticulous dissection to create bloodless fields and to make a pocket size similar to the width and height of the device. I currently offer all types of silicone gel implants ranging from shaped to round devices with varying degrees of cohesiveness and surface textures customized to the individual needs of each patient.  Looking at data collected from industry experts and reviewing my own personal results over the years I have concluded that the pectoralis major muscle, even if elevated with great precision, may introduce a number of variables overtime that reduce the long-term control of outcomes by surgeons.  It is my goal to provide patients with an excellently executed surgical procedure combined with a customized implant choice leading to a desired outcome for many years, without the need for multiple revisions. Therefore, if an individual’s breast anatomy has adequate thickness in the upper pole for optimal coverage over the implant without the need for additional thickness of the muscle then I will proceed with a sub-glandular/ sub-fascial placement of the implant.  If there is slightly less than adequate thickness I will recommend simultaneous autologous fat grafting to enhance the upper pole breast tissue as opposed to elevating the muscle.

Historically speaking, other indications for utilizing muscle in augmentation mammoplasty procedures was to reduce capsular contracture rates.  Most experts feel that biofilm is the major mechanism leading to capsular contracture. Bacteria flora in the breast ducts can be introduced onto the surface of the implant during surgery setting up colonization leading to many antigens triggering our immune system resulting in an array of events such as capsular contracture and even implant associated lymphomas. This idea, even with a dual plane placement of an implant under partial muscle coverage, reduces the surface area of the breast directly in contact with the device. Data shows a reduction in at least one percentage point in capsular contracture in the subpectoral plane compared to sub-glandular placement. However, thanks to the contributions of surgeon- researchers such as Dr. Bill Adams, our society has good benchmark data regarding the most appropriate irrigation solutions to combat the most likely bacteria present to control biofilm as well as intraoperative techniques to minimize bacterial loads on the implant during the procedure. Utilizing all this data has led to a very low capsular contracture rate even in the sub-glandular plane of my patients, thus, I feel the risk benefit ratio still favors avoiding the muscle.  

Additionally, another way to reduce capsular contracture in the sub-glandular plane is to place textured rather than smooth devices. The data is quite clear:  there is a 50% reduction in capsular contracture rates with textured vs smooth devices sub-glandularly.  But wait, it gets more controversial – textured implants have an increased risk of developing implant associated atypical lymphomas (ALCL).  Fortunately, the number of confirmed cases is very low compared to the very large denominator of all patients who have received breast implants since the late 1960’s.  In fact, the likelihood of being hit by a car while walking on the street is far greater than developing ALCL.  As far as I can glean from the data, there is no stratification of ALCL of textured devised in the sub-glandular vs sub-pectoral plane.  It is my belief without proof that the inflammation of textured devices under a dynamic muscle is greater than a textured device in the sub-glandular non-dynamic plane. The overwhelming majority of plastic surgeons in the United States utilize smooth implants mostly because, in the late 1990’s, textured saline implants resulted in poor outcomes with greater rippling under the muscle and higher deflation rates compared to smooth implants.  However, surgeons in Europe were never forced to use saline implants and always had the availability of silicone gel devices.  They have mostly embraced textured gels with excellent results and very low ALCL rates.  Based on all of the risk-benefit analysis combined, I prefer a sub-glandular textured breast implant for the vast majority of my aesthetic breast patients.  This device has the least capsular contracture rate with the least amount of risk for implant malposition inferiorly-laterally, and avoids a waterfall effect of the inferior pole breast tissue falling away from the implant which is held to the chest wall muscle, and avoiding any unnecessary muscle animation deformity of the breast during pectoralis muscle activation. I have also found the soft touch gels which are more cohesive than the workhorse responsive gels but less stiff than the highly cohesive gels to minimize rippling of gels in rather thin breast tissue patients. Even in the breast reconstructive realm where there is even less overlying tissue, the push for pre-pectoral placement of silicone gels completely wrapped in acellular dermal matrix material is gaining favor to avoid muscle animation deformities. For the prospective patient reading this blog don’t be hampered by simply listening to your girlfriend who had implants some fifteen years ago and tells you to have a augmentation with saline under the muscle because that is what she had and she is happy.  I applaud you for exploring implant options and encourage you to seek modern options with less long term negative outcomes with sub-glandular placement of textured implants.


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