You are in: eMedicine Specialties > Plastic Surgery > BREAST Breast Augmentation, SubglandularArticle Last Updated: May 27, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Howard T Bellin, MD, Chief, Department of Plastic Surgery, CosMedica - The Plastic Surgery Center of New York Howard T Bellin is a member of the following medical societies: American Medical Association, American Society of Plastic Surgeons, New York Academy of Medicine, New York Academy of Sciences, and New York County Medical Society Editors: Christian Paletta, MD, FACS, Professor, Division Chief and Program Director, Department of Plastic and Reconstructive Surgery, St Louis University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Lars M Vistnes, MD, FRCSC, FACS, Professor of Surgery, Emeritus, Stanford University Medical Center Author and Editor Disclosure Synonyms and related keywords: INTRODUCTIONSection 2 of 12
  One of the great debates in plastic surgery has focused on whether to place breast implants over or under the pectoralis major muscle. This author's strong feeling is that in most instances, the implant should be placed in the subglandular position, that is, over the muscle. History of the ProcedureBreast augmentation first was attempted in the early 1900s. The site of placement was always subglandular. Everything from ivory to ebony to paraffin was implanted and, of course, rejected. In the 1950s, Ivalon sponges were used. Although they were biocompatible, fibrous tissue grew into them, making them extremely hard. Breast augmentation was begun in earnest in the mid-1960s when silicone implants were introduced. Again, the placement always was subglandular. The major problem with breast implants consistently has been hardness. The implants themselves do not become hard; the problem is that the human body recognizes that the implant is a foreign object. Since the body cannot reject the implant (silicone has no active binding sites), the defense mechanism is for the body to wall it off with a membrane consisting of myofibrils and collagen. This commonly is termed a capsule. If the capsule contracts around the implant, the consequence is similar to squeezing a balloon partially filled with water—it feels hard. This is known as fibrous capsular contracture. Why the capsule contracts in some patients remains a mystery. Even more mysterious is the fact that it frequently occurs in only one breast and not the other. The early silicone implants had backing made of Dacron that was meant to hold the implant in place. What was not realized for several years was that the Dacron caused a severe tissue reaction, resulting in extreme capsular contracture. In the late 1960s, the idea of putting the implant under the muscle was introduced. This placement was popularized in the mid-1970s because of the belief that the breast felt softer with subpectoral implantation. Unfortunately, the characterization of the degree of hardness is difficult to quantify. Although the Baker system of classification is widely accepted for this purpose, determining just how much firmness a breast may have remains subjective, and therein lies the problem of finding the procedure that minimizes the problem. ProblemThe argument for subpectoral (under the muscle) placement is as follows:
The argument for subglandular (under the breast tissue) placement is as follows:
Nevertheless, approximately 50-60% of plastic surgeons perform submuscular implantations. This author places approximately 2% of implants under the muscle, usually only when requested by the patient. FrequencyMicromastia is a common occurrence. ClinicalDetermine the patient's motivation and expectation. Be wary of the patient who wants the surgery to please her partner. Try to match the patient's expectation to the effects that can be achieved. When a patient asks for very large breasts, the author inquires if she wants a natural appearance. The answer is almost always affirmative. In that situation, the author states that he will make the breasts as large as possible and still have them appear natural. On physical examination, noting asymmetry is important because the patient may be unaware of the problem; she may only note it postoperatively and blame the surgeon. Differences in nipple and breast height, size, and shape are common. Look for stretch marks and assess their depth. Also observe any thinning of the breast tissues since these problems cause a higher degree of rippling (wrinkling) of the implants. Note any degree of ptosis and advise the patient regarding how much will remain postoperatively. Except in extreme situations, the author prefers not to perform a mastopexy, since most patients are satisfied with the augmentation and whatever lift it provides and do not want the additional scarring. Failing that, a nipple lift is often sufficient. Obviously, locate any breast masses or discharge. During the physical examination, discuss the patient's desires and the size of the implant. INDICATIONSSection 3 of 12
Micromastia (ie, small breasts) is obviously the reason patients seek an enlargement procedure. However, surprisingly, what may appear to be ample breasts to the surgeon may seem quite small to the patient requesting augmentation. A patient occasionally requests surgery because of asymmetry. RELEVANT ANATOMYSection 4 of 12
The female breast covers the anterior chest wall from approximately the second rib superiorly to the fourth or fifth rib inferiorly. Its upper one half overlies the pectoralis major muscle, the serratus anterior its lower one half, and some of the axillary fascia laterally. The breast is essentially a skin organ. It is attached intimately to the skin by suspensory ligaments (Cooper ligaments). This is because developmentally it forms from the ectoderm of the anterolateral body wall, and epithelial proliferation from that site creates the gland. For this reason, opening the natural plane between the muscle and the breast is easy; an implant can be inserted into this space. The blood supply of the breast is derived from branches of the axillary artery, the intercostal arteries, and the internal mammary artery. Few if any vessels penetrate into the gland from the underlying gland. Its nerve supply comes from the anterior and lateral cutaneous branches of the fourth, fifth, and sixth thoracic nerves. One of the larger lateral cutaneous branches often can be visualized and preserved during augmentation surgery. CONTRAINDICATIONSSection 5 of 12
The one absolute contraindication to subglandular augmentation is an irradiated breast. Because of interference with the blood supply caused by radiation, a subpectoral placement is much safer. Another reason to consider placing the implant under the muscle is very thin breast tissue, as can occur after pregnancy. Some surgeons also believe that a subpectoral implantation should be used in extremely small-breasted patients, although the author feels this is necessary only in some patients. Because a small amount of the breast may be obscured during a mammogram, a patient with a strong history of breast cancer probably should be augmented under the muscle, as should a patient undergoing postmastectomy reconstruction when the contralateral breast also is being augmented. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Medical therapyDespite occasional false advertising to the contrary, no drug enlarges a female breast permanently. However, a device that stretches the skin externally is purported to cause proliferation of the underlying tissue to provide an increase of up to one cup size. It currently is undergoing testing as to its efficacy and the permanence of the result. Surgical therapyIn the author's opinion, micromastia is best treated with a subglandular breast augmentation. Preoperative details
Intraoperative details
Postoperative details
Follow-up
COMPLICATIONSSection 8 of 12
The prospective patient must be informed of the risks and possible complications of the operation. Infection Infection is a rare complication, which occurs, in the author's personal experience, in approximately 1 patient per 1000. It usually necessitates removal of the implant and replacement at a future date. Postoperative bleeding This occurs in 0.5-1% of patients. While it is not life threatening, it requires additional surgery to stop the bleeding. Deflation Several years ago, the author used textured implants in approximately 100 patients, and deflation resulted in 5 patients, which is highly unacceptable. Except for those 100 surgeries, the author has used smooth-walled implants in approximately 1000 patients since 1992 and has had no deflations. However, deflation is certainly a known risk and may well happen in the future due to fold faults, which are continuous flexing of the implant edge that, like repeated bending of a paper clip, can cause failure of the implant. Rarely, the filling valve can be defective. Capsular contracture Capsular contracture is the major problem with breast implants. If the capsule contracts around the implant, it squeezes it and makes it feel hard. This complication can be treated with closed capsulotomy but it may recur. Many studies demonstrate no difference in contracture rates when the implant is over or under the muscle. Vitamin E and zafirlukast (Accolate) are believed by some to reduce the incidence of capsular contracture. The author's incidence of capsular contracture with 2500 subglandular augmentations is between 5% and 7%. Rippling of the implant Although this occurs more frequently in patients who have thin breast tissue following pregnancy or who have deep stretch marks, it can occur in any patient. Silicone implants have a much lower incidence of rippling because the gel adheres to the elastomer lining, which helps to keep it from rippling. (Silicone gel implants will be allowed for all uses some day.) Hydrogel, where available, also results in less rippling. OUTCOME AND PROGNOSISSection 9 of 12
The implant manufacturers state that their products are not meant to be lifetime devices, but because of their long-term guarantees of replacement, they obviously hope that they will be used over the patient's life. Overall, the author has found a high degree of patient satisfaction with subglandular placement of breast implants and recommends that approach. Whatever the complications with hardness or rippling, almost no one asks for the removal of the implants. FUTURE AND CONTROVERSIESSection 10 of 12
A device is presently under investigation that stretches the skin externally and supposedly causes proliferation of the underlying tissue to provide an enlargement of the breast of up to one cup size. While the author believes not many patients will opt for this device because it is cumbersome to use, he also believes that its efficacy and the permanence of the result have yet to be demonstrated. Saline breast implants have some serious disadvantages, especially regarding how they feel and the occurrence of rippling. In addition, silicone implants are undergoing clinical trials in which the author is participating, and the author believes they will be available for general cosmetic use within a few years. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Breast Augmentation, Subglandular excerpt Article Last Updated: May 27, 2006 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
