WHAT IS THE BEST IMPLANT POCKET FOR BREAST AUGMENTATION?
Mytien Goldberg, MD, FACS • November 26, 2023
WHAT IS THE BEST IMPLANT POCKET FOR BREAST AUGMENTATION?
Mytien Goldberg, MD, FACS • November 26, 2023
Breast augmentation is the most popular cosmetic procedure performed worldwide each year. It is popular due to high patient’s satisfaction with the procedure including women reporting improved body image, self-confidence, and overall sexual wellbeing. In a breast augmentation consult, I am often asked this question by my patients, “I was told by a plastic surgeon “below the muscle” is the best implant pocket for breast augmentation. Is that true?”
Foremost, choosing the tissue plane i.e. implant pocket for implant placement is one of the key factors in breast augmentation. Generally speaking, there are 3 types of implant pocket techniques in breast augmentation
- Submuscular pocket technique – Dual plane technique
- Subglandular pocket technique
- Subfascial pocket technique
A. Submuscular Pocket Technique – Dual Plane Technique
In this technique, the implant is placed behind the pectoralis major. This is accomplished by releasing the muscle origin at breast crease on the chest wall and along medial aspect of the rib cage up to the level of the fourth rib. This maneuver allows the muscle to window shade up on the chest wall as illustrated in image 1. The implant superior pole will be covered by the pectoralis major muscle and the lower pole of the implant is cover by the breast tissue, thus term dual -plane. (image 2)
Image 1.
Image 2.
This technique is favored by most plastic surgeons for the following reasons:
- Increasing soft tissue coverage of the upper pole of the breasts results in less rippling and prevent shelve like appearance at the top of the breast where the implant meets the chest wall
- This technique has a reported lower rate of capsular contracture around 3 to 8
- Conceptually in the dual plane pocket, the implant sits in the subglandular pocket on the lower half of the breast which allows the implant to expand the deflated skin envelope without being limited by the pectoralis major muscle, avoiding a snoopy deformity or double bubble deformity. Snoopy deformity or double bubble deformity is characterized by breast tissue that appears to slide off the implant as appear in this picture. However, the patient in this picture had a dual plane submuscular breast augmentation
There are definite draw backs with the Dual Plane technique. Here are the main draw backs:
- There is more postoperative pain after the procedure due to the manipulation of the muscle. In some very active women with very well developed chest muscles, they do complain of long term chest discomfort and weakness.
- Animation deformity is an abnormal movement of the breast and implant due to contraction of the chest pectoralis major muscle. This is an unnatural and unnerving experiences for most women with subpectoral breast augmentation. It is not often seen in two dimensional before and after pictures. It is only evidence with movement of the arms and chest. It is most prominent in thinner patients.
- Overzealous release of the pectoralis major muscle along the sternum runs the risks of symmastia and ridge like deformity up in the chest wall.
- Submuscular dynamic laterization of the implant overtime is also a real issue that is not often listed as one of the potential draw backs of this pocket location. The contraction force of the muscle will push the implant laterally into the axilla. This is especially evident when a woman lays down and the implants will slide into the lateral chest wall.
- If the pectoralis major muscle is inadequately release, accessory muscle slips over the sternum, the implants can sits far apart resulting suboptimal cleavage. Furthermore, the implants can sit very high up in the chest wall giving a unnatural high riding implant.
Main disadvantages of Dual Plane breast augmentation
- Snoopy breast deformity or double bubble
- Wide cleave due to the limit of the pectoralis major muscle
- The technique is still prone to capsular contracture as illustrated in this patient
B. Subfascial Pocket Implant Technique
In this technique, the implant is placed below the fascia which is a layer covering the muscle. It requires meticulous dissection separating this fascial layer from the muscle. Which can be performed using a Bovie cautery in a bloodless meticulous fashion as illustrated in this picture.
- Fascia layer above the pectoralis major muscle
- Provides an additional layer to cover the implant
- Protect direct contact between the implant and breast tissue therefore lower rates of capsular contracture
- Improve cleavage in wide chest women because the location of the implant is not limited by the origin of the pectoralis muscle
- Minimal rippling even in very thin and active patient
- Most importantly No animation deformity
It is a less popular technique among plastic surgeons due to the fact that it is less frequently trained technique during residency (surgical training to become a board certified plastic surgeon). However, I personally in favor the subfascial plane over the dual plane technique for multitude of reasons
- It places the implant in a very natural plane where the added volume should be centered under the breast tissue.
- It allows the implant to expand both the breast tissue and skin in the most physiologic location where the volume should be added without the restriction of the pectoralis major muscle. This prevents any potential of double bubble or snoopy breast deformity
- No manipulation of the pectoralis major muscle, a major muscle of the chest, means less immediate postoperative pain and also discomfort in the long terms for most woman. Furthermore, it does not have the dynamic deformity force caused by contraction of the muscle or lateralization of the implant in the long term.
- Furthermore, without the limits of the muscle origin on the sternum keeping the implants apart, subfascial augmentation allows a surgeon to place the implant closer together creating a much more appealing cleavage in women with wide chest anatomy as illustrated in this patient.
5. The fascial layer provides an additional layer of coverage for the implant and prevents direct contact of between the implant and the breast parenchyma (unlike the subglandular pocket), and thus lowers the rate of capsular contracture. This has been reported in large series of subfascial breast augmentation reports in the literature. The reported rate of capsular contracture in subfascial plane is similar to that of dual plane technique.
6. For most active and athletic women, the subfascial plane allows the patient to continue with their favorite activities such as lifting weight, playing volleyball, tennis, and surfing without disrupting one of the most important chest muscles (pectoralis major muscle). These patients will not have animation deformity typical of dual plane technique.
C. Subglandular Implant Pocket Technique
In this technique, the implant is placed below the breast glandular tissue. This technique is seldomly used these days due to several factors:
- It has an abrupt sharp transition from the chest wall to the implant and thus would be less natural in appearance.
- It has potential rippling deformity due to lack of soft tissue coverage
- It has a higher rate of capsular contracture compare to the dual plane or subfascial plane
However, there are advantages to this technique
- It is less painful than submuscular or dual plane technique since there is no manipulation of the muscle
- For a deflated breast – subglandular plane does allow for expansion of the skin envelope and potentially create a lifted illusion to the breast without performing a breast lift and additional scar
Are you considering breast implant removal options but still want natural breast enhancement after implants? Do you wonder what your breasts will look like without implants? If so, you're not alone—and there are solutions to help you achieve a beautiful, natural shape. Embracing Your Body at Every Stage As we enter our 50s and 60s, we become more in tune with our bodies, appreciating the journeys they’ve carried us through—whether it’s childbirth, breastfeeding, or simply the ups and downs of life. Over time, some women find that breast implants no longer feel right. They may seem like a foreign material that no longer aligns with their bodies, prompting the decision to remove them and seek a more natural alternative. However, many women feel uncertain about breast explant surgery and how their breasts will look post-explant. Will they be saggy? Will they still have cleavage? These concerns are valid because, at any stage of life, we want to feel confident, empowered, and beautiful in our own skin. The good news? There are several breast implant removal options that allow women to maintain fullness and a natural shape using their own tissue. Your Options for Breast Implant Removal with Natural Fullness Option 1: Breast Implant Removal with Local Breast Tissue Rearrangement If you have a good amount of breast tissue with some skin laxity, this technique could be ideal for achieving natural breast enhancement after implants . The procedure involves removing the implants through a small incision in the breast fold. Dr. Goldberg then uses the lower breast tissue to enhance fullness and create natural cleavage. This method offers a soft, natural result without the need for artificial implants. Option 2: Breast Implant Removal with Lateral Chest Fat Transfer For women who do not have enough breast tissue for the first option, this approach utilizes excess fat from the sides of the chest to restore fullness after breast explant surgery with flap transfer (living fat tissue) . Many women in their 50s and 60s have loose tissue on the lateral side of the breasts. This excess fatty tissue is repositioned into the breast to restore volume and projection. The benefit of this technique is that the tissue is a living tissue which is different than fat transfer . It is simply a superior technique. The result? A fuller, natural-looking breast while simultaneously sculpting the sides for a sleeker contour—truly a win-win! Option 3: Breast Implant Removal with Abdominal Tissue Transfer (DIEP Flap Reconstruction) This is the ultimate solution for women seeking a full-body transformation while achieving breast reconstruction after implant removal . Dr. Goldberg removes excess lower abdominal tissue and repurposes it as living tissue to reconstruct the breasts. This technique provides long-lasting fullness while also improving abdominal contour—similar to a tummy tuck, but with the added benefit of breast reconstruction. It’s a fantastic option for women experiencing issues like Breast Implant Illness (BII), recurring capsular contracture, or those desiring a "natural" mommy makeover. Your Journey to Natural Confidence If you're ready to say goodbye to implants and hello to natural breast enhancement after implants , you're not limited to just one approach. With modern techniques like breast explant surgery with microsurgical flap transfer , you can achieve a youthful, confident look that aligns with your body’s natural beauty. Dr. Goldberg specializes in breast reconstruction after implant removal and natural enhancement techniques, helping women regain confidence and comfort in their bodies. 🔹 Ready to explore your options? Schedule a consultation today to discuss the best breast implant removal options for you!
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6 Minute Read: I received radiation treatment as part of my breast cancer treatment. What is the best breast reconstruction option for me: implant or autologous tissue breast reconstruction? If you have received radiation as part of your breast cancer treatment, I hope this blog is informative for choosing the best option for your breast reconstruction. After mastectomy, the goal of breast reconstruction is to recreate an aesthetic breast mound plus or minus the nipple and to establish symmetry with the remaining breast.
A breast lift is a surgical procedure that raises the breasts and restores their firmness and youthful appearance. It can be done with or without breast implants. As a woman ages, her breasts may sag due to a natural loss of skin elasticity, pregnancy, breast feeding, weight changes, and gravity. Breast sagging is completely natural, but it’s also reversible with a breast lift. You might be asking, what is a breast lift and how does it differ from breast implants? Breast implants make the breasts bigger and, by default, they can fill up any excess skin to cause the breasts to lift. A breast lift is a procedure that has the specific goal of raising the breasts, usually using the existing tissue. Implants are not necessary for a breast lift, though some women may choose to get them. A breast lift without implants is for women who are comfortable with the size of their breasts or women who would like a small reduction in their cup size. This procedure is also called mastopexy. During surgery, the doctor removes excess skin and tightens the surrounding tissue to reshape and support the new breast contour. The volume of the breast that fills a bra is left in tact, but their shape and position will be noticeably improved. A breast lift may be part of a ‘mommy makeover’ to reverse the affects of pregnancy and breastfeeding on a woman’s body. Since no implant is added during mastopexy, the results can be quite natural looking. Every woman is different. An individualized approach is taken for each patient to ultimately give her back youthful, firmer breasts.
Saline breast implant deflation occurs on average 4.3 to 6% at 10 years. A Study on silicone rupture rate (Inamed Silicone Breast Implant Core Study Results at 6 Years rupture rate published in Plastic & Reconstructive Surgery: December 2007 – Volume 120 – Issue ) was 3.5 percent overall at 6 year. Overall, the rupture rate of both silicone and saline implants are equivalent. The difference is detection of rupture. For saline implants, the rupture is detectable by the patient and physician almost immediately. However in case of silicone implants, the rupture is silent. It would require a radiographic study such as MRI or an ultrasound to detect silicone implant rupture. Retrospective study showed untreated silicone gel fill implants are harmless conditions (Plastic & Reconstructive Surgery: July 2004 – Volume 114 – Issue 1). Unlike a silicone implant, saline implant ruptures result in an immediate deflation of the implant and skin envelope of the breast. If the deflation goes untreated, the breast skin envelope would retract back while the other breast envelope continues to be expanded. Over time, you would have significant asymmetry in your breast that may require additional procedure to the unaffected breast such as a lift. Therefore, if you have breast implants and note any changes in your breast shape or size, you should consult your plastic surgeon soon for diagnosis and treatment. If it is a breast implant rupture, the two major breast implant manufacturers in the United States (Allergan and Mentor) provide a lifetime warranty for all of their implants. If an implant fails or ruptures during the first 10 years, both companies will provide a new implant and $1200 applicable toward operating room and anesthesia costs which can be upgraded to an extended plan providing up to $2400 for a small fee prior to surgery. All implants have a lifetime guarantee and will be replaced by the manufacturer if the problem is related to the implant.
In America and throughout the world, both men and women are expected to look healthy and young well into their 30’s, 40’s, 50’ and 60’s. While diet and exercise can play a large role in looking younger, the use of modern cosmetic surgery has become one of the most popular ways to beat back the clock. Getting surgical cosmetic procedures has become very commonplace, with an ever-growing percentage of the population opting in to get cosmetic surgery. Yet there is a large divide between women and men, and what procedures are most popular for each of the sexes. The American Society of Plastic Surgeons today released top line data from its 2011 plastic Surgery Statistics Report. The latest data shows breast augmentation is still the most common cosmetic surgery procedure for 2011. There were 307, 180 breast augmentation procedures performed in 2011, up 3.7% since 2010. Many of the common signs of aging that occur to a woman’s breasts as she gets older can be very devastating to her self esteem. Yet with today’s modern surgical options, there is a viable option for women to change the way they look. Second to breast augmentation, rhinoplasty is the most popular cosmetic procedure, with a total of 243,772 procedures being performed in 2011. The growing number of cosmetic procedures is an indication that even in this tough economic climate, more consumers are choosing cosmetic surgery as a way to look younger and feel better about themselves. We certainly see the same trend in our practice. More and more women are seeking improvements in their look. We support this trend as many of these procedures equate to improvements in their overall self-confidence and quality of life.
A new study published in the Archives of Facial Plastic Surgery in February 2012, looks at perceived age after facial plastic surgery. This novel study attempts to quantify the degree of perceived age change after facial plastic surgical procedures . A total of 60 patients were enrolled in the study and divided into 3 groups: Group 1 patients had only facelift and neck lift (total of 22 patients); Group 2 patients had facelift, neck lift, upper and lower eyelid surgery (total 19 patients); and Group 3 patients had facelift, neck lift, upper and lower eyelid surgery, and brow lift (total 21 patients). The investigators then asked a group of first year medical student to estimate the patient’s age based on the Before and After pictures of each patient. The researchers tried to standardize the photographs by asking participants to not wear makeup. The researchers found that on average, the raters estimated that the patients looked 1.7 years younger than their actual age before surgery, and 8.9 years younger afterward. On average, the estimated age dipped by 5.7 years in group 1 (patients with neck and face lift), and by 8.4 years in the third group (patients with neck, face lift, upper and lower eyelid and brow lift). Therefore, the author of the study concludes that facial rejuvenation surgeries demonstrate a significant and consistent reduction in perceived age. This effect is more substantial when the number of surgical procedures is increase. The desire to improve one’s physical presentation and to maintain a youthful appearance is intrinsic in our evolution. Physical appearance and how we are perceived by others have implications for social and psychological functioning, as well as our sense of well-being, self-esteem, and self-confidence. Before you seek to have plastic surgery procedures, do your homework and check that the doctor is board-certified in plastic surgery. There is a lot of white-coat deception. Virtually any kind of doctor legally claims to be a plastic surgeon without any formal training in plastic surgery. As a board certified plastic surgeon, I have seen increasing numbers of patients who present with complications and unsatisfactory outcomes after having procedures done by non board certified plastic surgeon.
Today’s society is one in which we can never seem to get enough. Everything is bigger, better, faster, and stronger. But what happens when you are blessed with too much of a good thing? While many women desire an increase in breast size, there are those who feel uncomfortable with size of their breasts. If a woman has large breasts, she may be considering breast reduction surgery for many reasons. Aside from feeling more comfortable in their bras and clothing, breast reduction surgery can help alleviate any number of symptoms. Women with large breasts often suffer from chronic back and neck and shoulder pain, chronic rashes and skin irritation under the breasts, deep grooves in the shoulders from bra strap pressure, poor posture and restricted activity, as well as poor self-image due to large breasts. Breast reduction surgery, also known as reduction mammoplasty, removes excess breast fat, glandular tissue and skin to help achieve a breast size that’s more proportionate to a woman’s body, as well as helping to alleviate the symptoms associated with overly large breasts. So who is breast reduction surgery for? Women of all ages have been known to have breast reduction surgery, even young women in their teens; however it’s strongly recommended that the patient wait until they are past the age of development. If a woman hasn’t started a family yet, or is still in the stages of family planning, it may be best for her to wait until pregnancy isn’t an issue yet, as pregnancy can change breast tissue. Results can be seen immediately, but it’s best to keep in mind that it can take months for the swelling to completely diminish and for the surgical scars to fade. For anyone considering breast reconstruction surgery, consult a Board Certified plastic surgeon. This is a very personalized procedure, and it’s important to understand everything that breast reduction surgery encompasses, including possible risks and complications, as well as set realistic expectations. I have insurance. Does that cover any of my procedure costs? If a patient has a history of chronic conditions, such as back, neck, or shoulder pain, or chronic skin conditions such as rashes or skin irritation in the breast issue, having a breast reduction may be considered medically necessary and is covered by most insurance plans. If approved, this means the patient’s insurance would cover the cost of the surgeon’s fee, as well as the cost of the facility and anesthesiologist. This is something that should be discussed and documented during a consultation with a board certified plastic surgeon. http://www.plasticsurgery.org/reconstructive-procedures/breast-reduction.html http://www.mayoclinic.com/health/breast-reduction-surgery/MY00778