Partial Sub-Muscular Placement (a.k.a. partial under & partial sub-pectoral)
* When discussing under the muscle placement with your surgeon, make sure he or she clarifies either PARTIAL or COMPLETE sub-muscular placement.
With partial sub-muscular placement, the upper 2/3 of the implant is behind the pectoral (chest) muscle. The lower 1/3 of the implant is not covered by the muscle. It is located behind the breast tissue.

• Decreased risk of visible and palpable ripples and implant edges, except for the lower 1/3 portion of the implant, which is not covered by the muscle/fascia.
• Decreased risk of capsular contracture.
• Most of the time, a more natural shape to the upper portion of the breast. In general, there is a more natural slope to the breast, instead of the "upper roundness" that is common with over the muscle implants. This is a good thing, if this is the look you desire.

• More post-op discomfort and longer recovery period. This is due to the procedure being more invasive, as well as the muscles stretching out to accommodate the implant.
• The implants take longer to "settle" or "drop".
• The breast implant may appear to be distorted while flexing the chest muscles. This is really not a big deal, unless you are flexing pretty hard.
• The implants are supported by the same tissues (skin) as over the muscle implants, which means less lower pole support (compared to implants placed completely behind the muscle/fascia), which can possibly lead to bottoming out, although bottoming out is possible with any placement.
• Ripples (wrinkling of the breast implant shell) may be seen and/or felt along the lower and outer 1/3 of the implant (the part which is only covered by the breast tissue). However, ripples are possible with the implants placed completely under the muscle, as well.

With this placement, the implant is placed over top of the muscle, but behind the breast tissue.

• Avoidance of a breast lift, or mastopexy, due to mild sag (ptosis), however, this is usually a "quick fix", and a lift will, many times, be needed in the future, especially when larger implants are placed. Keep in mind that the only thing supporting the implant is the skin and breast tissue.
• Less recovery time, with less post-op discomfort/pain, since the muscles are left in tact, and only skin and fat are cut.
• Larger implants may be placed, versus attempting to use a very large implant with partial or complete sub-muscular placement (during the first augment).

Cleavage is more easily created with over’s, particularly if the breasts are naturally spaced wide apart.

• Ripples are more easily seen and felt, especially in women starting with little or no breast tissue. In these cases, there are very little tissues to help camouflage the implant. This is especially true for saline breast implants placed over the muscle.
• More pictures/views will need to be taken when doing mammograms, and sometimes, insurance companies will not pay for these extra images, which mean you will have to pay for those out-of-pocket. However, his can be true no matter where the implants are placed.
• Capsule contracture rates are highest in women with implants placed over the muscle.
• Some women have complained of feeling self-conscious because their implants are just "out there", due to the implant only being covered by the skin and breast tissue. Thankfully, this doesn't seem to be a common complaint.

Many women who lift weights opt for over the muscle placement. This is mostly due to the fact that when the pectoral muscles are flexed, the implant does not become distorted in shape.

Complete Sub-muscular (a.k.a. complete unders, total sub-muscular, total sub-musculofascial, and full unders)
*When discussing under the muscle placement with your surgeon, make sure he or she clarifies either PARTIAL or COMPLETE sub-muscular placement.

Implants placed completely beneath the muscle are NOT totally behind the pectoral muscles. The top 2/3 of the implant is behind the pectoral muscles and serratus muscles, and the lower 1/3 is behind the fascia, which is the connective tissue that connects the pectoral, serratus, and upper rectus abdominal muscles. Having the implants completely beneath the pectoral muscles ALONE is not anatomically possible.

There are rumors that complete sub-muscular placement is not possible no matter how the surgeon performs the surgery. This is simply not true, and don't let anyone tell you otherwise.

Complete sub-muscular placement can be achieved via the transaxillary, periareolar, or inframammary fold incision (this can only be done with saline implants). However, when going with the transaxillary incision, the muscles and fascia can be left in tact. They do not have to be cut or dissected in any way. This is not so with the periareolar and crease incision. With these two incisions, the muscle must be dissected in one way or another, in order to place the implant behind it. Of course, there is the method of simply cutting, and afterwards, it is closed up with sutures, or allowed to heal on it's own.

Currently, complete sub-muscular placement is not widely used, though it is gaining increased popularity.

• The implant is fully covered, by the muscle and fascia, which helps to camouflage the edges of the implant, as well as ripples in the implant. While visible rippling is possible with all three placements, having complete sub muscular placement has the least risk of visible rippling.
• The fascia serves as support to the lower pole, whereas with partial sub-muscular placement, the skin tissues support the weight of the implant. Complete unders serve as sort of an "internal bra".
• Lower risk of capsular contracture.
• Better mammogram readings (versus over the muscle implants).
• Lower risk of bottoming out.

• More post-op discomfort.
• Breasts tend to sit a bit high at first, until the muscle relaxes.
• Implant distortion when the pectoral muscle is tightly flexed, which is also try with partial sub muscular placement.
• If your breasts are widely spaced, it may be more difficult to create cleavage, especially with textured implants.

Scar tissue that forms around the implant which causes the breasts to harden similar to what a contracted muscle feels; While capsular contracture is an unpredictable complication, it is also the most common complication of breast augmentation.

1. Textured implants help deter contracture because of their rough surface which is intended to discourage a hard capsule from forming.
2. Massage and or compression. This is usually only done with smooth implants and may be suggested for a period between a few weeks to as long as you have your implants. Do not massage bruises!
3. The "no-touch" technique. This method includes meticulously re-washing surgical gloves before handling any instrument and implants. Only the head surgeon touches the implant, using a unique Teflon cutting board and immediately inserting the implant underneath the muscle. All of these measures help ensure that no foreign substance attach themselves to the implant, which could inflame the surrounding tissue and cause complications such as capsular contracture.
4. Vitamin E -- Is rumored to help, it can't hurt and it also beneficial to the skin. However, it may cause bleeding so don't take 2 weeks before & after surgery.

1. Antibiotics - Surgeons use antibiotic for treatment of capsular contracture.
2. Zafirlukast (Brand Name: Accolate)
3. Capsulectomy

The most appropriate treatment for capsular contracture is complete capsulectomy, or removal of the entire thickened capsule surrounding the breast implant such as in the specimen shown below. This is the most likely procedure to prevent future recurrent capsular contractures from forming. Capsulectomy, or merely cutting the capsule to release the scar formation, is much more likely to lead to a recurrence of the problem. See how the specimen on to the picture is shown immediately following removal, and the breast implant is still contained within the intact capsule.

The capsule has now been incised without removing any of the capsule. This demonstrates the considerable compressive forces exerted on the implant by the thickened capsule. This is why capsular contractures often lead to increased firmness of the breast.

A close-up view of the cut edge of the capsule, demonstrates the thickening that occurs during capsule formation. A normal capsule is a flimsy, transparent structure. As thickening occurs, collagen is laid down in layer upon layer, ultimately becoming apparent as a change in the shape of the breasts, a change in the softness of the breasts, and in some cases causing pain.

The final photo in this series showing the capsule fully opened with the implant removed.