Breast augmentation is one of the most popular and requested procedures in cosmetic surgery. This is why patients must be well informed about the various approaches for implants placement. They influence the durability of the aesthetic result, scarring and the necessity of replacing the implants.
Jessica C. – Patient Testimonial regarding breast augmentation in Serdev Clinic [e-mail from October 2018]
“I am a past patient of yours, having undergone breast augmentation surgery in 2012. I must say, the procedure itself was fantastic, and I have not had any trouble since.”
Placement Location of Implants
1. Under the pectoral muscle, without weighing on the skin (subpectoral implants)
We place the implants under the muscle and they do not drop, because the muscle holds them in place. Due to the larger “pocket”, the result is natural. The bust is soft to touch and takes the natural body movement. Regular movement of the implants maintains the free space (pocket) and when touched, they will feel and move as natural breast tissue.
NB!! Only the pectoral muscle can hold the heaviness of the implants! Implants should be smooth and able to move naturally, without irritating or hurting the muscle. Textured implants get blocked under the muscle.
2. Over the pectoral muscle and below the gland, adding heaviness on the skin (subglandular implants)
Many surgeons prefer placing the implants above the pectoral muscle (under the gland and skin). However, this approach has a major disadvantage – the implants are too heavy and the skin alone cannot support them. Thus, in a few years the skin loosens and lengthens, breasts sag. What could be done then? In most cases, surgeons propose replacement with bigger implants, scarring mastopexy, or both.
Mastopexy is a method for reduction (lifting) of the ptotic breasts by excising the excess skin. Patients, especially young women, should gather information about the disadvantages of subglandular breast augmentation and the subsequent, sometimes multiple surgeries!
3. Under the fascia of the pectoral muscle
This method was not able to achieve wide acceptance. It consists of placing the implants above the muscle, but under its facsia, which has to support the impltans’ weight. It is suitable when surgeon is introducing the implats via incision in the armpits.
4. Half under the muscle and half under the gland
There is also an approach for placing the implants from under the breast, half between the muscle and half between the gland (or even the skin, because the gland is often small). In these cases, when the muscle contracts, it squeezes the upper half of the implant while the gland and skin in the lower part do not offer stable support. Thus, the implants can move downward in another position. In some cases implants can prolapse though the infraglandular incision.
Composition of the implants
In our opinion, saline implants are the best choice – they consist of an absolutely harmless sterile salt water solution. This is the same solution, which is transfused to all patients. It is unclear why they are not always presented to patients, which is mandatory in the USA and saline implants are used in 52% of all cases.
According to a publication from the Amrican Society of Pastic Surgeons, FDA allows the use of saline implants for breast augmentation to all women over the age of 18, as opposed to silicone implants, where the minimum age is 22. Anatomycal (teardrop shape) implants are heavy in their wide lower part. They may rotate after a sudden push, which requires surgery for their repositioning. In addition, when lifted with a bra, their upper and narrower part may protrude unnaturally, unlike round implants.
Smooth saline implants placed in a wide pocket under the pectoral muscle are softer than silicone implants with cohesive matrix. As our patients say – they move quite naturally, as thout they are “alive”.
Breast augmentation surgery lasts about 40 minutes. The shape of the breasts remains permanent. Saline implants do not require replacement. In contrast, silicone implants may need to be removed or replaced periodically. Patients can safely travel by airplane, but should protect the breasts from injury, unnatural pressure etc.
It is not necessary to wear a bra when the breast implants are placed under the mucle. If the patient chooses to do so, she must remove the busks to avoid hurting the breast tissue and changing the form of the new infra-mammary fold.
Implant Placement Approaches
There are several approaches for breast augmentation. The incisions for placing the implants can be under the breast, in the armpit, around the lower half of the areola, or the navel.
Most harmless and with least noticeable scars is the periareolar approach – incision on the border between the brown areola and skin. This is the most atraumatic access, going through the avascular plane (no blood vessels), without damaging any structures. The surgeon opens the muscle in its upper part, by separating its fibers without cutting. Therefore, there is no risk of postoperative prolapse (implant slipping out of position). The implants are placed in the free space under the muscle.
Surgery is bloodless and relatively fast. Due to the lack of trauma, pain is minimal and patients do not have social limitations. They can resume their regular daily activities on the day after surgery or within the following few days. Patients wear a tape in the wound between the areola and the skin for some days. Patients come for follow-up and post-op care, changing tapes and so on for 3-5 days. We recommend that patients do not wear bras, but rather elastic garments. in order the implants heaviness to keep and preserve the new lower folds of the pocket.
Incision under the breast
The approach with incision under the breast is most frequently used by the majority of surgeons. This is because the use of not sufficiently elastic, textured silicone implants requires a bigger excision. If the surgeon has to place the implants under the muscle with this approach, he must also cut the muscle. This makes healing more difficult, because the implant weighs on the stitches.
Incisions under the breasts and in the armpits are visible when the woman is in a laying position!
Rare complications, which you should be aware of, are the following:
– Early complications: bleeding around the area of the implant, infection, implant slipping under the incision or prolapse;
– Late complications: disturbances of touching sensation around the nipples, capsule contracture and dislocation of the implant (one-sided in most cases), implant rupture (in rare cases).
Breast Augmentation and Ptosis
In some cases of breasts ptosis after breast augmentation with implants, we can use scarless Serdev Suture method for Breast Lifting to elevate the breasts to a suitable level. The ptosis may be a result of giving birth and lactation, ageing etc. Dr. Serdev uses only a couple of skin puncture points to perform the procedure. There are no incisions and excisions of skin and therefore – no scars! In cases of more expressed ptosis, we may perform the procedure in stages.
The suture lift cannot be used however in patients with implants placed over the muscle (because of the implant heaviness), as well as in very large breasts.
Dr. Serdev’s method is also useful in corrections for treatment of Poland Syndrome, for lifting the developed breast and augmenting the underdeveloped breast.
Repositioning of Breast Implants in Symmastia and False Position
The Serdev Sutures method presents a new possibility for repositioning breast implants in cases of false position and symmastia. Symmastia is a condition defined as a joining of the breast tissue of both breasts across the midline anterior to the breastbone. It can be congenital or as a consequence of breast augmentation.
The surgeon performs this procedure through skin punctures only, in order to suture and fixate the stable fascias above and below the implant. Thus, we create a new, proper lower and medial line of the augmented breasts and also correct the implants’ position.
Wearing of elastic garments or a bra could be necessary for some weeks after surgery, in order to reduce the weight on the implants on the sutures.
Breast augmentation using fat transfer
This technique exists, but is not widely accepted.