Before discussing the placement of mammary prostheses, we will comment on the access routes, which are the areas where a small incision will be made to introduce the implant. To this date there are three approaches and, as in most cases, each has advantages and disadvantages.
- Areolar: The plastic surgeon will make a small incision at the lower edge of the areola in the area that limits the darker area of the areola and mammary skin. Among the advantages of this incision is that the scar that leaves is the least visible, since the scar will be in the area between the lighter skin of the breast and the dark area of the areola, hiding it much better. Just after 3 months the scar will be barely visible and it can be pigmented in case is a bit too whitish. Through this access, a direct visualization of the cavity can also be achieved, allowing the small blood vessels to coagulate, thus minimizing the possibility of capsular contracture. However, its disadvantage is that is not advisable to breastfeed after this type of surgery.
- Armpit: It is a more complicated route and it can be said that it’s “blind”, because the incision is made in the axilla, away from the breast. Therefore, the doctor must lower the prosthesis from the armpit to the groove. One of the disadvantages is that if the patient chooses anatomical prostheses, she will not be able to use the axillary approach.
- Sub mammary: The incision of about 4 centimeters is made in the mammary sulcus to access where the prosthesis is to be placed. The scar is more visible, but it does not touch the breast tissue because it reaches the pectoral muscle directly, making it the recommended pathway for women who have plans to breastfeed in the future. One of its disadvantages is that this approach is not advised if the lower pole of the patient’s breast is short, in that case the incision will need to be lower thus leaving a more visible scar.
Where is the implant placed?
Before analyzing the placement of the implant it is necessary to take into account that the specialists will take this decision based on an esthetic criteria. The plastic surgeon is the person in charge of defining the ideal option, according to the anatomical characteristics of the chest and the body of each patient.
Some doctors prefer to place all breast implants under the pectoralis major muscle – sub muscular – as it helps to achieve a more natural breast appearance and anatomy. In addition, placing it that way reduces the risks of a possible capsular contracture and facilitates the visualization of the mammary gland when performing a mammogram. However, there are three other implant placement types, which we will explain below.
This type is chosen when tubular breasts of a certain size will be used, and the reason is because in this type of breasts it’s necessary to make radial cuts in the glandular tissue to expand the breast and to have it open so that it adopts a wider shape and thereby covering the prosthesis. It’s a placement that is also used when mastopexy is done with prosthesis and the reason is because these patients have enough breast tissue to cover the prosthesis without being palpable or noticeable.
On the other hand, it has recently been detected that in female athletes with adequate skin coverage, implantation can be used in front of the muscle, with figures of capsular retraction similar to those obtained with retro pectoral implantation. With this placement you can get a breast shape closer to an ideal breast, but the risk to suffer a capsular retraction is greater.
- Among the advantages of placing this type is that implants move much less when it comes to sports or physical activity, since there is no direct contact with muscle (muscle contraction).
- The postoperative result will be more satisfactory than in the implants under the muscle, since usually the recovery and healing time is shorter.
- You will experience less pain in the first three to five days as there is no manipulation of the muscle and the little pain you’d feel can be controlled with painkillers prescribed by your doctor.
- There is less edema, which makes the results faster.
- There is a greater possibility of a capsular contracture, unlike patients who have implants under the muscle.
- With the passing of the years there may be greater weight loss and sagging of the skin, since there is no support.
- Mammography is slightly less accurate than when placed underneath the muscle. This aspect should be taken into account by the patient when there is a family history of breast cancer.
In this type, the prosthesis is placed underneath of what is called fascia, that is, the tissue that covers the pectoralis major muscle. The prosthesis is placed behind the mammary gland supported on the pectoral muscle and wrapped by the fascia. It’s one of the favorite positions of plastic surgeons, as long as there is sufficient tissue at the subcutaneous level -2 cm of tissue- to cover the upper pole of the prosthesis. Also this type is made when the anatomical or tear shape prostheses will be used.
However, when choosing a round prosthesis, the sub muscular type is more advisable, except in cases where the patient has enough breast and her objective is to increase one or two sizes. Similarly, if you are an athlete and like to practice climbing, fitness or swimming is also the appropriate route of placement. In this case the risk of capsular retraction is lower.
This type of technique does not have a great difference with the sub glandular technique, given the fine thickness and it’s better to disguise the prosthesis rebound. Therefore, we can affirm that there is no technique better than another, in each case we must assess the advantages and disadvantages between one and the other and make the best decision.
The prosthesis goes under the muscle and it’s better for thin patients with small breasts or a very tense skin. For these cases, the plastic surgeon will recommend using anatomical or round prostheses, because patients don’t have enough subcutaneous cellular tissue to conceal the prosthesis. Currently, there is a belief that if the implant is placed at the sub muscular level, its lifespan increases, but it’s just an assumption and nothing else.
- This type of placement can disguise the implant very well because there is a whole muscular layer that covers it, which makes it easier to hide it.
- It decreases the risk of capsular contracture.
- Provides a more natural breast, avoiding excessively round or unnatural breasts.
- There may be more postoperative pain, since the muscle is separated from the rib cage and causes a greater muscle tension due to the implant.
- The mammary gland takes longer to get a natural form, until the muscle it’s healed.
- This placement is also not recommended for patients with developed pectoral muscles or patients who make a lot of physical effort with the arms, because when they contract, the prosthesis tend to move up or out, which gives a somewhat unnatural effect.
It‘s when the prosthesis is placed under the fascia -a thin layer of pectoralis major muscle- to ensure that the upper edge of it is not visible even in slim women.
Possible common risks
It’s necessary to take into account that some risks are the same for all implants: prosthesis rejection, keloid scarring, hematoma, partial loss of nipple sensitivity and seroma.
It’s important that, regardless of the type of surgery, patients should follow the guidelines of physicians by strictly adhering to them to avoid any complications after surgery.
Don’t forget, good results will depend always in the information, knowledge and expertise of the surgeon. A great doctor will have the best results for you.