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Patients are very well-educated these days. One of the first questions asked is where the pocket is going to be. Submuscular or subglandular? This is an important question because the location of the pocket affects the appearance of the implant and the breast for many years. The original position was subglandular. This was an easy pocket to make and initial results were very good. However some patients developed hardening of the breasts (capsular contracture), and some patients also had ripples and wrinkles. You could feel or see these from across the room. Some of them developed the softball on a stick.

Surgeons tried to correct this by going to a deeper level underneath the pectoral or chest muscle. For the most part this worked. Implant edges weren’t as visible or as palpable to touch. The chance of capsular contracture was less and overall implants looked better.

Most plastic surgeons use implants in the submuscular position, especially in those women who don’t have much tissue in the chest (i.e. most breast implant patients). Sometimes women have sufficient soft tissue coverage and the choice to go subglandular seems reasonable. Sometimes women have tubular breasts and the breast can do better with the subglandular approach.

The downside of submuscular placement is that the implants move up by squeezing of the chest muscles and the breasts can look funny at the moment of contracture. This applies to doing bench presses or flys. It only lasts for that brief moment in time. The solution may be as simple as wearing a different shirt rather than a tank top

The downside of subglandular is the patient may feel wrinkles or ripples especially with saline. They tend to look more round rather than blending with the normal breast tissue. In addition a large subglandular implant especially Saline can drift down and cause sagging of the breasts more than a submuscular implant would.

In general thin women do much better with submuscular placement. Heavier women also do well with submuscular placement but some can tolerate subglandular. As I said in another blog there are no bad choices just better ones.

What is a living bra?

It is a surgical technique designed to give you the most support, the most natural padding, and the best feeling breast possible. This system of doing breast augmentation uses your own muscles to create coverage and support for an implant. To show how this works, these figures will demonstrate the principles and power of muscle support.

Your anatomy: The chest muscles are directly under the breast. Usually the pectoralis muscle only goes to the nipple level and the other muscles cover below this. The rectus and external oblique muscles cover the middle and laterally toward the side. The serratus muscle covers the rib cage.

When implants are put over the muscle, just under the breast there is no support underneath. Sometimes this works well, but with larger implants this may cause bottoming out. This is a situation where the bottom part of the breast becomes fuller than the top. Also, wrinkles and ripples can be more obvious anywhere in the breast because of the lack of coverage.

One solution is to put implants under the pectoralis muscle. This prevents upper half wrinkling and rippling but doesn’t do that for the lower half especially on the side. The muscle does support the implants, but there is no muscular support on the bottom.

A better solution for support and coverage is the living bra. The implant placed under all of the muscles of the chest: pectoralis, rectus, external oblique and serratus. Then a relaxing incision is made toward the middle and bottom of the pocket. The muscles on the side help to cup and contour the implant for the best padding and support.