Dr. John B. Barnett
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Reasons Not To Have Submuscular Breast Implantation

POSTOPERATIVE PAIN: Postoperative pain is extremely intense in almost all cases of submuscular augmentation.  The patients who have had this operation usually described a tremendous degree of deep, searing, unrelenting pain and spasm lasting from a few days to one or more weeks in duration.  This pain is due to constant spasm of the chest wall (pectoralis major) muscle which has been elevated and displaced from its normal location.  The pain will ultimately diminish due to muscle fatigue; however, it is almost invariable delays return to normal activity for a prolonged time.

CHEST WALL MUSCLE ABNORMALITIES: The muscle stretching out or thinning with results in loss of mass and strength.  Surgeons who recommend submuscular placement of the implant content that the bulk of the pectoralis muscle will aid in “camouflaging” or hiding any implant ripples that may occur.  This is a false assumption because as skin stretches to accommodate the implant, so does the muscle tissue, which in a short period will not provide any significant bulk.  Also, the muscle never covers the laterals side of the implant.  Therefore, if a ripple is going to appear, it is going to show on the sides, and basically if it is going to ripple then it is going to ripple.  The muscle gives NO bulk or protection – not even theoretically.  Muscle thinning (attenuation) is permanent, and normal strength will never return.

DEFORMITY: Even though the muscle is thinned out and is not normal, it still retains enough “Power” to contract.  This leads to abnormal “strange-appearing” implant movement when the muscle is activated.  This looks distinctly abnormal and is troubling to many patients.

DOUBLE BUBBLE: An indentation in the lower part of the breast can be present due to a “banding” of the lower part of the chest wall muscle, causing two bulges, above and below the implant. 

RIPPLES: A very annoying entity associated with some saline-filled implants, (can also occur with silicone gel implants) is rippling.  This is more likely in patients with thing skin and/or not much breast tissue, but with saline implants, adjustments can be made during the procedure.  Placing the implant underneath the muscle does NOT change this!  Sometimes, an implant flaw is to blame, and may ultimately require replacement.

WIDE STERNUM (BREAST BONE): It is much more difficult to achieve acceptable “cleavage” with a wide breast bone.  There is a limit to how close the surgeon can placed the implants together using the submuscular approach.  The “on top of the muscle” approach makes it much easier to obtain a more normal cleavage.

OUTWARD PROJECTION OF THE NIPPLE-AREOLAR COMPLEX: Because of the above limitations toward the center (breast bone), the nipple may point abnormally towards the sides.

IMPLANTS USUALLY “RIDE TO HIGH”: A normal, natural breast has a slight slope from upper chest to the nipple-areolar complex with the bulk of the breast volume in the lower portion or lower pole.  The nipple show be approximately in line with the mid upper arms.  With submuscular implants, the muscle holds the implant too high, creating too much volume high on the chest wall.  This often gives the “just got a shot in the back with two cruise missiles” appearance.

CAPSULAR CONTRACTURE: Capsular contracture or hardening of the scar tissue around the breast implant is going to occur in approximately 15-25% of people of unknown, but probably multifactorial causes.  In spite of claims otherwise, there is NO difference in the rate of occurrence of capsular contracture or hardening of the breast implants with regards to the surgical approach.  Correction of this is exceedingly difficult, if at all possible, with submuscular implantation.  This is not the case with the above-the-muscle location.  Surgery, yes, but much more easily accomplished.

DANGER OF PNEUMOTHORAX (COLLAPSED LUNG): This is an uncommon, but certainly well-known possibility with submuscular approach.  To make the space for the implant, the muscle is raised up off the ribs and their intercostal or “between the ribs” muscle which aids in respiration.  These muscles are VERY THING, exposing areas that are vulnerable to perforation allowing air into the lung space, causing the lungs to “collapse,” thus requiring re-expansion with a chest tube.

SILICONE GEL VERSUS SALINE-FILLED: The majority of women have asymmetrical or uneven size and/or shaped breasts.  For saline implants, the surgeon can adjust accordingly during the operation.  With gel implants, you are stuck with a set size, unable to adjust.  Softness or “natural” feel is essentially the same.

UNNECESSARY BREAST LIFTS OF MASTOPEXY: Women who have a natural-appearing breast, but simply want enhancement are often told that they need a breast lift to achieve the desired results.  In MANY cases, this simply NOT TRUE.  The uplift is recommended because with the implant held up high, the natural breast will “drop off” downward off the implant, giving a “Snoopy’s nose effect.”  The uplift requires a much longer, more difficult (especially artistically), more expensive operation, which also by the way, leaves significantly larger, longer and more prominent scars.

"Dr. Barnett was great. He reminded me of our family doctor I used to see growing up. He really seemed to care and his work was very good."
– Maria G.