The truth about under-the-muscle breast implants [Dan Zegzula, MD, Portland]

Eva Sheie (00:00):
You're listening to Where Before Meets After.

Dr. Zegzula (00:03):
When you do a breast augmentation on a patient and you put the implants under her pectoralis muscle, then that muscle will forever be somewhat changed. Because of the presence of that muscle, you have to cut some of the pectoralis muscle to get the implant under it. And then whenever the patient contracts the pectoralis muscle, there's always an action on the implant causing the implant to shift and the muscle is stretched and not quite in its anatomic position. So I have had patients tell me that implants under the muscle have changed the way they exercise, the way they use their arms in their chest when exercising. So not as many bench presses, not as many pushups, burpees, anything where you're pulling or pushing with your arms can be affected by that. It doesn't mean that they can't do it, and there are many women in the gym that have their implants under the muscle.

(00:51):
But if you ask those patients, do your breasts move when you contract your pec muscles? And they almost always will say, yes, it does. So in that way, breast augmentation can affect the way they exercise. I avoid that because I'm a big fan of putting implants above the muscle. There's a couple different terms for it. One's called sub glandular, the other's called subfascial. There's a thin layer of connective tissue called the fascia above the muscle. And I do try to preserve that, and when I'm doing above the muscle breast augmentation, I try to put the implant under the fascia. But when you do the augmentation that way, then you're not going to have interference with the pectoralis muscle when it contracts and you're not going to have discomfort when the pectoralis muscle contracts. So I'm a big fan of above the muscle breast augmentation and most of the newer implants and our techniques have evolved such that we can get really good natural looking results when the implants above the muscle.

Eva Sheie (01:42):
When you see those videos of implants that are visible, they're clearly post-op. They're showing you, look, when I flex my implant moves or when I put my arms a certain way, you can see the outline of the implant. What is happening when you see a video like that?

Dr. Zegzula (02:02):
There's different reasons for that. Some of the images of bad boob jobs that you might have in your mind is exactly that, where you can really see the outline of the implant. The implant looks very round, very hard looking, and sometimes ripples on the surface, that's that waviness on the surface that's not natural. Sometimes those patients are really lean and have very little breast tissue and they put really big implants in. Sometimes there may be bad choices in planning of the surgery. Sometimes those patients are having a complication called capsular contracture. Capsular contracture is when you build up scar tissue around your implant and the squeezing of that scar tissue because the scar tissue contracts and it makes the implant look very round and sometimes misshapen. That's a hallmark of one of those images of a bad breast augmentation.

Eva Sheie (02:57):
There's a terminology out there called the dual plane, and if you move around in any social media spaces around breast augmentation, this is a very common conversation that women are having, you know, where, what's your placement? Did you do dual plane? Did you do above? Did you do below? I think it's really confusing for people? How does the dual plane differ from what you're doing or from the two techniques that you mentioned earlier?

Dr. Zegzula (03:26):
That's a good question, and I do think there's some confusion about that. It sounds like it's something different. Like what is dual plane? Is it above? Is it below? What is it? And a dual plane breast augmentation is a type of under the muscle, it's a type of submuscular breast augmentation. But what makes it a dual plane is that they release the muscle from the overlying breast tissue so that the muscle retracts up higher on the breast and then only the upper part of the implant gets covered by muscle. And the lower part of the implant is really just behind the breast tissue. That's dual plane. So partly under the muscle on the upper part of the breast and then partly behind the breast and the lower part. When that technique came out about 20 years ago, it was touted as solving some of the problems with under the muscle operation and not having as many problems as purely above.

(04:23):
Honestly, I think it doesn't do a great job of either. I'm not a huge fan of dual plane because the muscle activity on the upper part of the breast will still make the breast push down, make the implant push down below the breast, and you get a lot of animation of the breast. So when they flex, their breasts move quite a bit. The upper part where the muscle is covering the breast can look very pretty and very natural, but really only at rest, the more active the person is, the more they'll notice activity of their chest muscle moving the implant around. So I guess another way to say it is, dual plane is a hybrid operation where you're both above and below the muscle at the same time as opposed to completely above the muscle, which is where I would prefer the majority of the implants that I put in to be.

Eva Sheie (05:05):
Thanks for listening. I'm your host, Eva Sheie. Follow the show and submit questions for our experts at wherebeforemeetsafter.com. Where Before Meets After is a production of The Axis.