So, I do about 150 to 170 breast augmentations a year. I’ve been using Mentor® implants since 1992. It’s a great implant, I like the feel of it. It’s much more natural than the other main implants out there. I’ve always used smooth wall implants long before it was in vogue. Now, most people use smooth. I actually talked to Mentor® and I’ve done over 6,000 breast augmentations so far.
I’ve always done them under the muscle, again long before it came in vogue. I don’t believe a breast augmentation over the muscle is a good idea and people ask, “Well, do you do it over or under and why?”
Breast augmentation over the muscle destroys the suspensory ligaments of the breast. And so you have a much higher chance of the breast drooping after surgery in the incoming next few months or few years. It also exposes the implant to a lot of breast tissue, and so in my experience capsular contracture or hardening of the breast is much more common with implants over the muscle.
Finally, as the breast tissue gets compressed over time with the implant over the muscle and as years pass, if a woman comes back in and she needs a breast lift, a breast implant over the muscle can present very, very dangerous situations for this surgery of a breast lift at a later date. For those and many other reasons, I very much prefer going under the muscle and I always have — I think over the muscle is just a mistake.
Over the muscle also leads to the problem of the implant being visible, people who get breast augmentation are often slender ladies. They’re often slender men but that’s a different topic. And so an implant over the muscle is basically subcutaneous in the upper chest, that’s why women get breast augmentations because they have a petite breast, so the implant is going to extend beyond where she has breast tissue and it’s underneath the skin.
And it’s funny how often I see this particularly out in Hollywood and in California. I see women come from Hollywood and they’ve got implants over the muscle. You’ve got an obvious implant line here or worse they’ve got saline implants which are going to show rippling and I’ll talk about that in our next V-blog about silicone vs. saline, but I put them under the muscle and I think it’s a much better approach.
In my approach to breast augmentation as far as my surgical approach goes, I almost always go through an incision underneath the breast. Now women often ask for an incision near the areola. In many Caucasian women, white women that scar is going to show, and you’re going to have two little happy face lines there for the rest of your life. Every time you take off your shirt and look in the mirror you’re going to see them.
I’ve never had to revise a scar underneath the breast because it’s underneath the breast you don’t see it, you don’t really care. Even if you don’t have a breast fold now you will at some point after your breast augmentation and that scar is innocuous. It’s about an inch long to an inch and a half depending upon what type of implant we’re putting in and it hides very nicely.
You can also put an implant in through the axilla, and I don’t favor that either because when you’re sleeveless, if you’re unfortunate enough to get a bad scar, you’ve got a bad scar for a very long time that could be revised, but often times it’s visible. Sometimes they’re not, it can be very nice but the problem is that I can’t do some of the things I do at the lower pole.
When I do a breast augmentation I do what’s called a dual plane technique. Now the dual plane technique has been written about recently in the literature and it’s been popularized. I’ve been doing it for 20 years. The dual plane technique detaches a bit of the breast tissue in the lower pole of the breast off of the muscle.
Then we lift up the muscle and we release the muscle of the lower rib here, we put the implant under the muscle. By doing it this way the muscles slides up a little bit and the lower pole opens up. That combined with my usual preference to not have my patients wear a bra for six weeks after surgery, allows the weight of that implant to open up that lower pole and let it drop.
If you look at my web site and you look at my breast augmentations, they just look a little bit subtly different than other people’s because mine sit down a bit more and I have noticed that other people’s breast augmentations sit up and still look a little bit fake or artificial. Sometimes people come in and say, “I want the fake look.”
No problem, I can do that too. We’ll keep you in a bra from the get go and they’ll stay up there for sure.