Above or Below the Muscle? The Truth About Breast Implant Placement

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:10):
Hey, Dr. Koehler and Dr. Gardner.

Dr. Koehler (00:13):
Hey Kirstin.

Dr. Gardner (00:14):
Hey.

Kirstin (00:15):
Today we're going to talk about breast implant placement. How much does implant placement actually matter for your results? Is it something that patients should really think about or is it mostly a surgical decision?

Dr. Koehler (00:29):
Well, you're talking about potentially two things here, where the implant is placed above or below the muscle and how it is placed actually physically on the person's body. But yes, the placement of the implant is critical where it's positioned. But as far as above the muscle and under the muscle, that's a big discussion. I'd say there's definitely a more favorite way. I'd say the vast majority of surgeons favor under the muscle placement, but there are times when above the muscle makes sense.

Kirstin (01:00):
When surgeons say over the muscle or under the muscle, what is actually happening during surgery? What's physically different between the two?

Dr. Gardner (01:09):
Well, in over the muscle, it's basically below the mammary or breast tissue on top of the pectoralis muscle. So we're creating a pocket and you're placing the implant, whereas a submuscular placement, you're either going through the muscle creating a submuscular pocket, either completely wrapping or encasing the implant, or you may release some of the muscle inferiorly and do what's called a dual plane where it's partially under the muscle and partially under the breast tissue. So they're different in the sense that you have to look at things like mammography and other things that can be a little different because if it's under the muscle, it's farther away from the breast tissue. Now any implant can make mammography more difficult, but if it's under the muscle, it makes mammography a little bit easier. But for the most part, it has to do with capsular contracture. And every time an implant is placed just like a port or a generator for a pacemaker, anytime something's placed in your body, your body is going to create a capsule around it.

(02:16):
It's a scar capsule, and that's a normal process, and we call them a pocket or a scar capsule. Well, what can happen is your body can continue to put or lay down collagen, and you can actually get an implant that is becoming squeezed by the surrounding capsule, and that is called a capsular contracture. If that happens, it can make the breast become more firm and if it continues to progress, it can even distort the breast and cause that side or one side to elevate and eventually become painful. So those are the different stages of a capsular contracture. And it happens more when the implant is on top of the muscle because when you place it below the muscle, either completely or partially, it doesn't matter. Every time you move your arm, you are massaging that capsule. The muscle squeezes, and it puts pressure on the capsule, and that's what keeps the capsule soft over time. And so the reason we like to place them below the muscle is you get auto massage of the capsule, which decreases the rate of capsular contracture.

Dr. Koehler (03:21):
Yeah.

Kirstin (03:22):
I like the education. Yep. Ditto.

Dr. Koehler (03:27):
And another big reason is that there's been a lot of research into why capsule contracture happens and why does it happen more to some people than to others. And it's a multifactorial thing. But one of the main factors that is a contributing that contributes to capsule contracture is bacteria. There's certain strains of bacteria that are in our body, and there are naturally occurring within the breast tissue. And so if you put an implant adjacent to the breast tissue, there's more of that bacteria that can get onto the surface of the implant. Now, it doesn't cause an infection, it just creates what they call a slime layer. The bacteria sort of colonize along the implant surface, and that is what in turn can stimulate that thickened scar tissue. Whereas when the implant's under the muscle, there's less of that bacteria present because the implant is not directly in contact with as much breast tissue where that bacteria normally resides. Another reason why under the muscle tends to be favored, and some people are much more prone to developing this than others, but it is one of the nuisance things that happens with implants.

Kirstin (04:39):
Well, when we're talking about over the muscle versus under the muscle, is there a physical difference after you're healed on how those two different options look and feel in real life?

Dr. Koehler (04:50):
Well, first of all, the recovery is different. Just say that first. If you go above the muscle, you will be feeling just fine the next day because you're not lifting up that muscle, you're not stretching that muscle. So those patients have a much quicker recovery. But then as far as look and feel, I mean, I think they both can look good depending on the size of the implant and how it's done. So I think they both can look good. And same ways feel if you use silicone implants, if they're placed above the muscle or under the muscle, if you have enough of your own breast tissue, even if it's above the muscle, it can still feel supernatural. But we have a lot of patients that get implants that have very little breast tissue, so more tissue coverage is better to feel natural, so then going under the muscle makes more sense.

Dr. Gardner (05:37):
Yeah, I agree. Elevating or anytime we manipulate a muscle, whether or not it's sewing muscle together and doing an abdominal wall plication during a tummy tuck or manipulating the muscle and implant placement, that hurts. And like Dr. Koehler said, those are the patients that have a little longer recovery and it's just sore and it just takes time to get over. But they still do great. So it's not something that you should worry about, but yeah, it can make a difference.

Kirstin (06:07):
Okay. What are some of the biggest myths or misunderstandings that you've heard from patients over the years talking about over versus under the muscle?

Dr. Gardner (06:18):
Yeah, I don't know that there are any. I think that for a long time, the general rule was place them over the muscle. And that's why when you see somebody that has older implants, a lot of times they are on top of the muscle, so they come in for an implant exchange and they may have to be switched from above to below the muscle. So it can make things a little more complicated. But as far as myths go, I mean, I can't really.

Dr. Koehler (06:45):
Well, and to your point there, if we look back historically prior to the implants being taken off the market in the late eighties, everybody was getting silicone implants. The vast majority of people were getting silicone, and those felt very natural, and you could put them above the muscle. It was an easy recovery, and they felt natural. But then when silicone got taken off the market and the only thing that was available for cosmetic use was saline, now all of a sudden doing that same implant above the muscle would not look good. It would ripple, it would not feel good. It would feel like a bag of water. And so it was almost like out of necessity, people had to have their implants placed under the muscle when they had these saline implants just to get something that felt good and looked good. And so that went on for quite some time until back in early two thousands now that the silicone is now back on the market for cosmetic use. And so I think for all of those years, it's like the preference was under the muscle, and it sort of stayed that way. And for a lot of the other benefits that we saw, which was decreased likelihood of capsule contracture, and the recovery is not significantly different. I mean, it is different, but it's not bad. I can't think of any myths. I don't know.

Dr. Gardner (08:05):
The only myth that I can think of is that implants last 10 years, and that doesn't have to do with overrun of the muscle, but everybody comes in saying, well, they're 11 years old, I think I need to have 'em replaced. I was told they last 10 years. I think that's just a misconception. Most of them come with a warranty, and the warranty typically is 10 years. And so a lot of people think that, oh, I've got to have it replaced within 10 years, and that's just not the case. We see patients that have had implants placed 25, 30 years ago that the implant is still, the device is still functioning, it's still intact, still working, and then we see others that for whatever reason, may have a implant that's less than 10 years old and it could be ruptured, which is low risk. But anyway, that's the only myth that I could really think of.

Dr. Koehler (08:54):
And if you have saline, you'll know if it's ruptured, it'll go flat. So that's the nice thing about saline. You don't have to worry about imaging or wondering if you're walking around with an implant that could be ruptured. The silicone devices, I mean, yeah, if you want to know if you implant is ruptured, and it's been 10 years, I mean, getting some imaging for sure to see if the shell's intact. I mean, there's lots of little things you can do to sort of make those determinations of when to replace them.

Kirstin (09:25):
How do certain lifestyles come into play when choosing over or under the muscle? Is there a different option for somebody with low body fat who may be a bodybuilder or something versus somebody who's not super lean and has a little more breast tissue? Does that change where you may place the implant?

Dr. Koehler (09:44):
Well, for me, there's only two reasons that I would typically go above the muscle, and it would be a patient that has drooped through their breasts that wants to be larger in size, that is unwilling to do a lift and is fully understanding that they're going to end up with a bigger breast, but it will still be droopy and it might get droopier because it's, so that would be one reason. And it's rare that I do that because once I explain all that to people, they're like, no, that's not what I'm looking for. And the other would be if it was a competitive bodybuilder that is doing poses on stage where they're in full flex, then yes, above the muscle. But if you notice those people too, unfortunately, they have such low body fat that it doesn't look natural in either position. It just doesn't move as much when it's above the muscle. So they're literally just sitting under the skin. These people have no body fat, and so it looks like a ball in there. I have some patients that are in bodybuilding that I don't know, maybe not at the highest level, and their implants are under the muscle, and I think they look so much better when they are. So those would be my only two reasons I can think of that I would do it.

Kirstin (10:58):
Are there certain breast shapes that make one placement a better choice over the other one?

Dr. Koehler (11:04):
No. We have techniques to help improve the shape, so I don't think above or below the muscle it matters in those circumstances.

Kirstin (11:12):
Do you ever have patients concerned about animation deformity when you go under the muscle?

Dr. Koehler (11:19):
We talk to people about it. I mean, if you're going under the muscle, I mean they move.

Dr. Gardner (11:26):
I agree. And that's, I think, not a deal breaker for most people. It does take some, I guess, getting used to, and I do have patients that when they work out, they just maybe do less chest work, they stop doing pushups, they stop doing bench, and usually it becomes a non-issue.

Kirstin (11:44):
Okay.

Dr. Koehler (11:45):
I have had a few patients that have had sort of more severe animation deformities, mostly related to some dual plane placements, so that when they flex, you'll see it's like you get a double bubble or more of an exaggerated double bubble. And the breast tissue kind of, I don't know if you know what I'm talking about, Vince, but it kind of pulls away and it looks bad. Those are a little harder to correct. But with the use of mesh and other acellular dermal matrix, we can actually fix some of those animation deformities. It depends having the implants move, that's normal, but sometimes you'll get other sort of stranger kind of deformities related to the muscle and the breast tissue pulling away from the implant.

Kirstin (12:30):
Do you ever have patients coming in thinking that they're certain that they want one type of placement and then you change their mind after fully evaluating them?

Dr. Gardner (12:39):
I don't see that as a big issue. I mean, I think once you discuss it with them, most people are on board with placement, and typically that's under the muscle. I mean, like Dr. Koehler said, it's rare that you're going to have somebody that's truly what I would say is a candidate for over the muscle. So I think maybe there's, once you educate somebody and discuss it with them, then I don't think it's really an issue, and I haven't had anybody really fight me on that.

Dr. Koehler (13:07):
Yeah, I mean, the only time, I guess there's one other circumstance where I go above the muscle and that's already there. If somebody has 'em and they look decent and they just want to change out their implants, well, we're not going. If they look good and they're happy, we're going to just keep it in the same position if they're not contracted. So that would be another reason to stay above the muscle. But yeah, I will say that for people who did have implants above the muscle and then let's say later in life developed droop or other things, these become actually very complicated. Not complicated, but more complex surgeries to correct them when they're like, oh, I want them perky now, and I want 'em more lifted because now we got to go from an implant that's sitting above the muscle to under the muscle and do a breast lift. And by the way, you're laying down and everything's sitting this way, and we got to get everything all lined up. It's like a very challenging surgery, and there's sometimes a few different ways to approach that problem. But anyhow, it's something that we do all the time. So it's not unusual by any means, but that is the only downside of having had implants above the muscle. And as you age, then having to switch them to a different plane might pose some challenges.

Kirstin (14:20):
Everyone loves a good before and after deep dive, but sometimes people end up saving wish photos that look nothing like their in body type. And we've talked about this before, how can someone tell if the results that they love online are actually achievable for them?

Dr. Gardner (14:35):
I mean, obviously coming in for a consult and evaluating them and doing their chest wall measurements and seeing what they're, they'll bring in their photos on their phone and they'll say, okay, I want to look like this. And if you can get 'em there or make it reasonable, but sometimes you can, sometimes you can't. So I don't know.

Dr. Koehler (14:56):
Yeah, I was just going to say, you need to have a trained professional in the consultation, looking at the photos, discussing what you're wanting to achieve, and then looking at your anatomy to say if it is possible or not. So they themselves can't go online. Yes, we would always encourage people, find people at your same height and weight or look like the same build. But it's interesting to me, I have people will show me pictures of like, oh, I really liked hers, and I think she's kind of like me and I'm like, no, she's actually not. I mean, your chest is way broader. Your cleavage is more open. I mean, I'm not sure what part of the picture you thought looked like you. Maybe the hair color, but the breasts don't. They don't match. And so you need to train professional. I will say this, I don't like video imaging or these imaging softwares. We had one in our office for what I think five years, and actually I've used it several others over the years.

(15:52):
And I will say the only time that it actually was helpful is I had the one where it was virtual reality. And so we take a picture and then they put the virtual reality glasses on, and then they could look at themselves in a virtual mirror and see their breasts, and then they could even look down and look at their breasts. So anyhow, I was doing a consultation with this girl, and she's doing the virtual, and she looks down, she goes, oh, oh, no, no, no. They've got to be much closer together than that. And I was like, okay. Anyhow, we took the glasses off and it prompted a very good conversation because of the shape of her chest, the position of her nipples, and it was like that video imaging, although a lot of reasons I don't like it because it's not accurate in a lot of ways, but it did point out something to her that was very important to her, and it was like, well, yeah, it's putting it where they're supposed to be and it can't bring them together like that.

(16:46):
So there are some other tools that can be helpful, but there's nothing that's foolproof. I think having a consult with somebody who can guide you realistically when you bring pictures in and say, is this achievable?

Kirstin (17:00):
Come in with an open mind. Do you have a burning question for our doctors or me? You can leave us a voicemail on our podcast website at Alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Gardner. Dr. Koehler,

Dr. Koehler (17:13):
Thank you.

Dr. Gardner (17:14):
Thanks.

Kirstin (17:15):
Go back to making Alabama beautiful.

Dr. Koehler (17:17):
You bet.

Announcer (17:19):
Got a question for Dr. Koehler. Leave us a voicemail at Alabamathebeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.