Pre-Pectoral Breast Augmentation Redux
In a previous Blog (Over vs Under: Which Comes Out on Top), I discussed the Pre-Pectoral plane for breast augmentation— commonly referred to as the “over” placement of breast implants. The Pre-Pectoral plane is increasingly adopted by Plastic Surgeons; however, many clients continue to be surprised that this is an option and some surgeons continue to dismiss this as a viable option.
In the following Blog, I will be discussing why the Pre-Pectoral Plane has emerged as an an excellent option for both breast augmentation and reconstruction and why it continues to be misunderstood.
When Silicone breast implants were first introduced in the 1970s by Cronin and Gerow, the logical plane of insertion was the Pre-pectoral space. This was consistent with anatomic principles. In fact, during my Plastic Surgery training, many senior surgeons would state that the best results in breast augmentation were from a pre-pectoral insertion of a smooth silicone implant.
In the 1990s, the incorrect claim that silicone implants were linked to a host of autoimmune diseases resulted in a moratorium in the United States and Canada on silicone breast implants. Silicone implants were replaced by Saline filled implants although the shell continued to be made of silastic silicone.
Saline implants posed several challenges to surgeons as they tended to be associated with rippling and this problem was solved by increasing the soft tissue coverage over the implant which meant recruiting the pectoralis muscle to camouflage the implant. Thus the Sub-pectoral plane, or Under, gained popularity. It was also believed that the continuous massaging action of the pectoralis muscle would reduce the complication of capsular contracture which was reported to occur in 6-8% of all breast augmentations. A modification of of the sub-pectoral placement was the Dual Plane in which the upper two-thirds of the implant was covered by the pectoralis muscle and the lower one-third was covered by breast tissue.
The Dual Plane implant insertion was believed to offer the best of all worlds — that is to say, it provided improved soft tissue coverage, reduced capsular contracture, and resulted in a shapely projecting breast. It has largely replaced the sub-pectoral plane of insertion.
Recent advances in the manufacture of silicone breast implants has resulted in the availability of Optimally filled silicone implants — we are now able make implants in which approximately 96% of the shell volume is filled with silicone gel. Furthermore, the silicone gel is form-stable or a “gummy bear” implant. Theses two factors have almost eliminated the occurrence of rippling.
Capsular contracture is reported at roughly 3% and we now understand that it results from bacterial contamination or small blood clots around the implant. Both these factors are addressed with meticulous no-touch surgical techniques.
Virtually all problems with cosmetic breast augmentation can be traced to the sub-pectoral position of the implant including animation deformities, gradual lateral migration of the implants, double bubble deformities, and waterfall deformities.
If we can place an implant where the final result has no rippling, no visible edge, and no difference in capsular contracture rates — why would we not select the Pre-pectoral space, or Over, technique?
I have been offering pre-pectoral Breast Augmentation for the last 4-years. In my experience, we have had no occurrences of capsular contracture and the cosmetic result is superior. I have also noted that clients recover faster and experience less discomfort during their recovery. In fact, this is part of our Rapid Recovery Breast Augmentation.
On a final note, there is no evidence that placing the implant in the pre-pectoral space interferes with screening mammograms or breast self-exam.
To learn more about breast augmentation or breast reconstruction, please arrange for a personal consultation at the Reddy Aesthetic/Reconstructive Institute.
P. Pravin Reddy, MD is a Board Certified Plastic & Reconstructive Surgeon and a member of the American Society of Plastic Surgeons.