How to not look like you have half a grapefruit sitting on your chest [David Levens, MD, Coral Springs]

Dr. Levens (00:00):
Hi, I'm Dr. David J. Levens. I'm a board certified plastic surgeon in Coral Springs, Florida.

Eva Sheie (00:06):
One thing I see all the time in the crazy Facebook groups is the controversy that is not really controversial, but under the muscle, over the muscle, dual plane, this position is right, this position is wrong. How do you think about that? How should we think about implant position?

Dr. Levens (00:30):
Very important topic, and there are four incisions. One is the armpit, the other is the belly button, so those are the most uncommon. Belly button is extremely rare. Armpits, probably 5%. The most common is an incision in the fold under the breast or at the nipple. I use both, but my favorite is at the fold. And then my favorite placement is a pocket that is partially under the muscle. So when we say under the muscle or subpectoral, we really mean dual plane, because technically the muscle inserts down onto the chest wall. And if you put an implant only under the muscle, it's going to be sitting up here. So we always release the bottom of the muscle, and when we release the bottom of the muscle, the lower part of the implant is actually covered by breast tissue. So it's technically a dual plane.

Dr. Levens (01:33):
However, there are different levels of dual plane where you release more and more depending on the position of the nipple and what the breast tissue is like to favor the appropriate positioning. And then above the muscle is much less common. The issues with above, so below the muscle is definitely better, much more common, traditional, better for mammography, less likely to develop encapsulation and less likely to have visible implant rippling for a patient, especially thin skin, thin tissues. If someone has thicker tissues, more coverage, they can get away with an implant on top of the muscle. They have to be prepared for the potential that maybe the mammogram's not as good, maybe the implant will be visible. But there are a couple other advantages of above, less problems with the contraction of the muscle that can shift the implants or so-called dynamic deformity that can cause the implant to kind of move around, which is probably part of the reason why the encapsulation is less likely because there's motion.

Dr. Levens (02:44):
And then the other issue about above the muscle is not as painful. And if you're a bodybuilder, which they tend to be lean anyway, they may not want to disrupt their chest muscles as much, even though the function is fine. But especially if they're very lean, it could really look literally like a half a grapefruit sitting there. But that's a decision that you would discuss with the patient. So I think that pretty much covers everything. There is one more there position, which is called sub fascial, that I've never done personally, and it's still at the meeting, very confusing. But there's a thick layer on top of the muscle called the fascia, and you're placing the implant between the muscle and that fascia, which can be a very thin layer, but it's in areas of thick layer. And I find it hard anatomically to conceptualize and to do it. But of course there are people that doctors too, that say that's the best way to go because it's the best of two worlds. You get the protection of the fascia, little less contamination with the breast tissue, less of the dynamic thing and et cetera, et cetera. So that's the exhaustive list of placement.

Eva Sheie (04:01):
Where can we find you?

Dr. Levens (04:03):
My office is at 1725 University Drive, suite 300, Coral Springs, Florida 33071. My phone number is (954) 752-1020. And then DrLevens@drLevens.com is my email. Website is DrLevens.com. I do have three Instagram pages, one with at Dr David J Levens. One is Plastic Surgery Talks and one is Levens Med Spa.

Eva Sheie (04:37):
On this podcast, we bring you directly to the doctors who are, where before meets after. Links to our guest's website and contact info are in your show notes. Follow us on Instagram @wherebeforemeetsafter. If you're a board certified plastic surgeon and would like to be a guest or a sponsor of the show, go to wherebeforemeetsafter.com for more information. Where Before Meets After is a production of The Axis, the podcast agency for aesthetics, theaxis.io.