Over or Under. Which Comes out on Top?
Clients seeking to undergo breast augmentation are faced with the important decision whether to select placement of the breast implant under the pectoralis muscle (under) or on top of the muscle (over) or in the sub-glandular position.
When breast implants were first introduced in the 1970s, the over, or sub-glandular, plane was preferred. As experience with breast implants accrued, it became apparent that Capsular Contracture occurred in roughly 8% of patients. In an effort to reduce capsular contracture, the sub-muscular plane was adopted resulting in reduced capsular contracture.
During the Silicone Implant Moratorium in the United States from the years 1992-2006, only saline implants were available for general use in elective breast augmentation. Saline implants were associated with rippling and the sub-muscular plane proved to be an effective means of camouflaging the implant.
As the sub-muscular plane was adopted as the preferred plane of implant placement, several problems with this approach emerged. In many cases, the implant did not project as well and the implants demonstrated unsightly animation with activation of the pectoralis muscle – such as when executing a bench press motion.
These problems were improved upon by using a Dual Plane technique. In this approach the breast implant resides partially under the muscle in the upper pole of breast and under the breast tissue at the bottom of the breast. The pectoralis muscle is often detached from it’s origin in the breast bone in order to create the necessary pocket and reduce animation of the implant. The Dual Plane technique offered the advantage of a better camouflage and shape to the augmented breast while reducing capsular contracture and animation of the implant – in other words, the best of both approaches.
Although many of my colleagues maintain the sub-muscular, or under, technique does not weaken the pectoralis muscle, it has been my observation that patient’s note decreased exercise strength. In addition, one can directly observe attenuation of the pectoralis muscle and the simple fact of detaching the muscle necessarily weakens it.
Improvements in implant technology, such as texturing of the silastic shell, and cross-linked silicone gels – popularly known as gummy bear implants, have resulted in decreased capsular contracture and surface irregularities. Therefore, the sub-glandular plane has once again emerged as a viable option with a superior aesthetic outcome while not disturbing the pectoralis muscle. The prerequisite for an over implant is adequate tissue coverage determined by your surgeon using the Pinch Test.
One concern with the over technique is that it interferes with Screening Mammograms. When undergoing Screening Mammography, one should inform the mammographer of the presence of the implant and in what plane. The test can be accordingly adjusted to carefully examine the tissue adjacent to the implant to ensure no lesions are missed. There is no evidence that the presence of breast implants is associated with increased risk of breast cancer or delayed detection.
It is my practice to discuss all options with the client when considering Bilateral Breast Augmenation (BBA). When adequate soft tissue coverage is available, appropriate consideration to the over technique is given. Should the client prefer an under implant, the Dual Plane technique is offered.
It is important to consider life style when deciding between under and over implants. For example, clients who enjoy weight lifting or bodybuilding may prefer the result of an over implant due to the reduced animation and weakening of the muscle.
Dr. Reddy is a Board Certified Plastic & Reconstructive Surgeon with additional training in breast surgery.