Implants can be inserted either behind the muscle or in front of it, between the muscle and the breast tissue. If the implant is placed in front of the muscle, there's less disturbance during surgery because only the breast tissue is being cut and manipulated to make room for the implant; the muscle does not have to be stretched over the implant. Implants in front of the muscle may also look more dramatic right away because they're closer to the surface and produce better cleavage and more projection.
Implants behind the muscle are flatter, may appear less natural, and can be displaced with muscle movement. Athletes generally prefer the placement in front of the muscle so as not to interfere with their chest muscle functions.
"Capsular contraction" or scarring can produce a firm breast over months or years in a few percent of saline implant patients. Silicone gel implants, however, may have a capsular contraction rate of 20 percent. This can happen with implants in front of or behind the muscle, and the studies, in my opinion, aren't clear about which placement is better.
Putting the implants under the muscle also results in a very painful recovery. Some women say this is worse than a caesarian section recovery! We usually use a pump that gives the patient a slow flow of local anesthetic for three days to minimize the pain (costs about $250 more) when using this surgical approach.
One reason for placing the implant behind the muscle is that the muscle covers the top part of the implant and produces less rippling, or visibility of the slightly irregular edge of the implant, on the top part of the breast. This is an advantage for women who originally have small breasts. High profile implants, however, usually don't have a lot of rippling even for women without a lot of natural breast to cover the implant. Rippling of the lower and outer part of the implant isn't affected by the placement position, as the muscle doesn't cover the implant there anyway.
Wearing a bra 24 hours a day, seven days a week for the first six months after surgery can help prevent any rippling effect, which may be caused partly by sagging. You want the healing process to support your new breasts, and the "capsule" or natural, soft scarring around the implant to be supportive rather than all stretched out, as it will be if you don't wear your bra. Your doctor should carefully fit you with a sample bra after the surgery, and you should look for bras which match his model. You will probably need a second type of bra several weeks after surgery, after the swelling goes down. The whole breast should feel supported by the right bra, and there should be some pressure on your shoulder straps.
As you can see, there's a lot of room for individual judgment in these decisions and the wise patient makes her decision in consultation with her physician.
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