Implants in front of the pectoralis muscle are known as suprapectoral or prepectoral implants. This is a much easier placement for the plastic surgeon, but in the long run, these suprapectoral implants have a greater chance of getting hard (capsular contracture). They also have an unusual look since normal breasts tend to have a gentle slope from the collarbone down to the nipple. With suprapectoral implants, there usually is a flatness from the collarbone to the upper portion of the implant, and then a jetting outward of the implant which has a relatively phony appearance.
Implants behind the muscle are called retropectoral or subpectoral implants. These have a more natural appearance since the pectoralis muscle inserts both on the clavicle (collarbone) and the 5th rib. When the pectoralis muscle is separated from the 5th rib, the upper portion of the muscle is flattened by the action of the pectoralis muscle, but the lower portion jets forward usually just behind the nipple areola complex giving it a very natural teardrop appearance.
For unknown reasons, retropectoral implants have a greater tendency to not get a capsular contracture than prepectoral implants, i.e. they stay softer.
With reference to a mammogram, subpectoral implants are preferred by mammographers because there is a density (the pectoralis muscle) between the breast tissue and the implant, therefore making the reading of a mammogram much easier.
What all the above means is that implants behind the muscle stay softer, look better, feel more natural, allow a better mammographic reading, and all in all, give a more sophisticated and attractive breast augmentation.
If you have thin chest wall skin, placing implants in front of the muscle can look phony and ripples will be more visible. Behind the muscle positioning of breasts implants provides most women a more natural looking result.
They do look different. Placing the implant behind the muscle gives you a natural taper look as the strongest portion of the muscle is on the upper breast. This portion of the muscle presses on the upper portion of the implant which helps to prevent the round balloon look. Placing the implant behind the muscle also reduces the chance for breast hardening (capsular contracture). However, if you have droopiness to the breasts, an implant in front of the muscle may help to correct this droopiness better than placing it behind the muscle.
There are many differences in the appearance of implants subglandular vs subpectoral. In my practice we always place the breast implant subpectoraly as it lends itself to the most natural look and feel. Additionally by going below the muscle, the implant does not interfere with the breast tissue and mammary ductal system and will not obscure breast imaging studies.
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