(214) 220-2712
2801 Lemmon Avenue West
Suite 300
Dallas, TX 75204

Chapter 6


“No set of surgical options or implant options is perfect for every patient— every option has trade-offs.”

Many different surgical options exist in breast augmentation. To be able to offer you options, a surgeon must be familiar with different approaches and implants and have the experience and skill to apply those options confidently.

No specific set of surgical options is best for every patient.

If you are offered only one set of options, that may be the only options a surgeon can offer—consult other surgeons.

Every patient tends to think that the options she chose are also the best options for someone else. that isn’t true because no two women are exactly alike. Your tissues are definitely different!

No surgical option is perfect.

No surgical option is without trade-offs.

The question is whether you know the relative benefits and trade-offs and pick the options that best maximize the benefits and minimize the trade-offs.

If you and your surgeon don’t discuss your tissues and how your tissues influence the best choice of implant for you, you will need to blame something or someone for the consequences.

You will probably blame the implant or the surgeon, when it’s really you who’s largely responsible.



Over or Under Muscle?

The most important priority in selecting a pocket for the implant is to assure optimal tissue coverage over your implant for your entire lifetime. Optimal tissue coverage means assuring that all portions and edges of your implant are covered by the most tissue available, given your body characteristics.

If your tissues are thin in the areas that cover your implant (and we will show you how to measure later), you may need to put the implant partially behind muscle, especially in the upper and middle areas of the breast, to assure adequate tissue cover over the implant. If you don’t, you run more risks of seeing the edges of your implant and seeing visible traction rippling later, both of which are usually uncorrectable. But there is much more to making the decision.


Breast implants in the past have been placed in one of two locations:

1. Behind your breast tissue but in front of your pectoralis muscle— retromammary placement (Figure 6-1), or

2. Partially behind your pectoralis muscle— partial retropectoral placement (Figure 6-2).

Now there is a new and frequently better option: dual plane1—behind muscle in the upper breast and behind breast tissue in the lower breast—the best of both worlds (1&2) above, while minimizing the trade-offs of each! (Figure 6-3)

When silicone-gel-filled implants were available and widely used in the United States, surgeons began placing implants partially behind the pectoralis muscle because silicone-gel implants had a lower risk of capsular contracture (excessive firmness) when they were placed partially behind the pectoralis. With today’s saline-filled implants, the risk of capsular contracture is about the same whether the implant is placed in front of the muscle or behind the muscle. So, what difference does it make, and how do you choose? The choice is based on the thickness of your tissues—how much thickness you have to cover your implants.


What Muscle, and Where Is It?

Let’s review our anatomy from the Introduction. Figure 6-4 shows a cross-sectional side view of the upper body. Let’s look at the layers of tissue beginning with the skin over the breast. Beneath the skin is a layer of fat—variable from patient to patient. The skin and fat layer make up what we call the “skin envelope” of the breast. The skin envelope covers the breast tissue, the next deeper layer. Beneath the breast tissue is the pectoralis major muscle that lies on top of your ribs. Implants can be placed behind the breast tissue but in front of the pectoralis (retromammary), or they can be placed behind the breast tissue and behind the pectoralis muscle (partial retropectoral), OR behind muscle in the upper breast and behind breast tissue in the lower breast (dual plane¹). To understand why we use the term “partial” retropectoral, let’s look at a front view of the anatomy.



The pectoralis muscle lies beneath the upper half or upper third of the breast. When an implant is placed in front of the muscle, the implant is covered in the lower portion by breast tissue and in the upper portion by only skin and fat (Figure 6-5). When an implant is placed behind the pectoralis major muscle, the upper portion of the implant is covered by muscle, but the lower portion (especially the lower, outside portion) of the implant is still covered only by breast tissue (Figure 6-6). Hence,the term “partial” retropectoral—the implant is only partially behind muscle in the upper breast. In the lower breast, the implant is not totally covered by muscle.

Partial retropectoral placement means that the upper portion of the implant is partially covered by the pectoralis major muscle and that attachments of the pectoralis muscle along the fold under the breast are left intact. In dual plane, some of these attachments are released to decrease the amount of pressure the muscle puts on the implant in the lower breast (more about that later).

Below and to the side of the pectoralis muscle is the serratus muscle. Although this muscle can be lifted to provide total muscle coverage of an implant, this option is best reserved for difficult reconstruction cases, not for augmentation. When an implant is totally covered by muscle (total submuscular), the shape of the lower breast is seldom as good and never predictable. The fold beneath the breast (the inframammary fold) is flatter and doesn’t stretch as predictably with time. The additional pressure of the serratus muscle on an implant can also cause upward displacement of the implant, requiring reoperation. These trade-offs generally mean that:

Although technically possible, total muscle coverage is never the best option for a first-time augmentation.

Rare exceptions exist where total muscle cover may be a good choice, but only in very, very thin patients who will accept all of the trade-offs listed above.

Retromammary (Behind Breast Tissue Only) Placement— Benefits and Tradeoffs

The goal of augmentation is to produce the best breast. The implant helps produce the best breast by putting pressure on the overlying breast tissue and skin envelope to fill and shape the breast.

An implant placed in front of the muscle (behind breast tissue, retromammary) can sometimes control breast shape more predictably, but . . .

If you are thin, placing the implant in front of muscle in the upper and middle edge of the breast may not provide enough coverage to prevent your seeing the upper edge of the implant, now or in the future.

Newer dual plane techniques allow surgeons to provide you the best coverage for your implants and provide you an optimal aesthetic result.

From a practical standpoint, what are the advantages of retromammary (behind breast only) placement?



Advantages of Retromammary Placement

Historically, surgeons have believed that advantages of placing the implant only behind breast tissue and not behind muscle (Figure 6-7) included the following:

More precise control of cleavage—the distance between your breasts,

More precise control of upper breast fill—especially upper fill toward the middle of your chest,

Less chance of muscle pressure pushing your implants to the side over time, widening the distance between your breasts,

Less chance of distorting your breast shape when you tighten (contract) your pectoralis muscle,

More rapid recovery following surgery? (this is no longer true.2,3)

With all these supposed advantages, why in the world would you ever put an implant behind muscle? There’s one overwhelming reason—to provide optimal, long-term soft tissue coverage over the implant so you don’t see the edges of the implant or see visible traction rippling in the future when the weight of the implant pulls on thin, overlying tissues. The best news is that now, with the development of dual plane techniques, you can have virtually all of the advantages of submammary placement, and at the same time provide muscle coverage in the upper and middle areas of the breast . . . and be out to dinner the same evening in most cases.2,3

If you are thin and you place your implants only behind breast tissue, you will have a greater risk of feeling or seeing an edge of the implant. How thin is thin? How do you determine when “thin” is “too thin”? In a moment, we’ll tell you. Another issue with placing implants only behind breast tissue and not behind muscle has to do with mammograms. More about that later. For starters, memorize this one:

The number one priority in breast augmentation is providing optimal soft tissue cover over an implant for your lifetime.

If you are very thin, adequate tissue cover is more important than all of the advantages of retromammary placement combined and is always the first priority.

The main trade-offs of retromammary placement are:

1. This location may not provide adequate soft tissue cover to prevent your seeing the edges of your implant or developing visible traction rippling as you age, especially if you are exceedingly thin.

2. This location may make your mammograms more difficult (more about this later). This placement potentially exposes your implants to more bacteria that are present in every woman’s breasts.

Subfascial Placement—Benefits and Tradeoffs

The pectoralis major fascia is a very thin layer of tissue that lies beneath the breast tissue but in front of the pectoralis muscle (Figure 6-8). Recently, some surgeons have promoted placing implants behind this layer instead of just behind breast tissue as a superior alternative to deeper submuscular or dual plane locations (discussed later in this chapter).


The pectoralis fascia is less than one millimeter thick at its thickest portion, and much thinner than one millimeter in many areas. No surgeon has ever proved that it is possible surgically to accurately lift this fascia intact or keep it intact to cover an implant. Most surgeons who promote subfascial placement claim that its benefits are essentially the same as the retromammary pocket discussed previously in this chapter. These same surgeons claim that patients have less pain and a faster recovery with implant placement under pectoralis fascia compared to placement under the muscle itself. Unfortunately, none of these claims is verified by valid scientific data, and subfascial placement is really no different than retromammary placement.

Later in this chapter, we will discuss a modification of placement under muscle, called dual-plane placement,1 that offers more than ten times the amount of additional soft tissue cover compared to the paper thin pectoralis fascia. Patients having dual plane placement routinely go to dinner the evening of surgery and resume full, normal activities within twenty-four hours.2 No surgeon using subfascial placement has ever demonstrated or published equivalent rapid recovery. Long-term follow-up of large numbers of patients using dual plane techniques has demonstrated an overall reoperation rate lower than is reported in any equivalent peer-reviewed and published studies.1-4 No comparative results with subfascial placement have ever been published.

Subfascial pocket placement adds less than one millimeter of additional soft tissue coverage over your implants.

A one millimeter or less amount of additional coverage is totally insignificant long-term as you become older and your tissues become thinner.

No long-term, scientifically valid comparative study has ever demonstrated any difference between submammary (retromammary) and subfascial placement.

No objective study for speed of recovery has ever matched the twenty-four-hour recovery we have demonstrated with dual-plane placement.1,2

Partial Retropectoral (Behind Pectoralis Muscle, Figure 6-9) Placement—Benefits and Trade-offs



Advantages of retropectoral placement

You already know the main advantage of putting an implant partially behind muscle—to prevent seeing an edge of the implant and to prevent visible traction rippling in areas where tissue coverage is thin.

The major advantage of placing an implant behind muscle is to prevent implant edge visibility and visible traction rippling.

This does not mean that you may not feel portions of the implant, especially in the fold under the breast and the outside portion of the breast.

A second stated advantage of subpectoral placement is better reduction of risks of capsular contracture compared to retromammary placement, especially with silicone-gel-filled implants.

Historically, differences in capsular contracture rates are more marked with silicone-gel implants than with saline implants. With saline implants, risks are about the same.

Better mammograms? Maybe, but a soft breast that can be pulled away from the chest for mammography is also important.

A third stated advantage of retropectoral placement is that some radiologists believe that placing the implant behind muscle improves mammogram interpretation. Although this concept is well-established in the medical literature, it’s not an absolute. (Remember, most medical “facts” are shades of gray.) One of the most important requirements for getting a good mammogram is that the breasts are soft (no capsular contracture). If the breasts are soft, it’s easier for the technician to pull the breast tissue forward (away from the implant) to get a better picture. Other factors can significantly affect mammograms: the skill of the technician performing the mammogram, the skill of the person interpreting the mammogram, and the consistency and characteristics of your breast tissue—just to name a few. Also, mammograms are not perfect, with or without implants. Earlier, we told you that a significant number of breast cancers may not show up on a mammogram. A mammogram is not the only way to assess a breast. Your personal exam and your physician’s exam are equally important. Remember, every implant interferes with mammograms to some degree. If you have a strong family history of breast cancer (mother and grandmother), don’t have a breast augmentation. Ask your surgeon about mammogram issues with implants; then make your own decisions.

Trade-offs of retropectoral placement

When an implant is placed behind the pectoralis muscle using conventional submuscular techniques (not the newer dual plane techniques), the following trade-offs can occur. They may occur to different degrees in different patients, but you should be willing to accept them, if neces- sary, in exchange for minimizing risks of upper implant edge visibility and possibly for better mammography. The pressure of the pectoralis muscle overlying the implant causes the following:

Distortion of breast shape when you tighten (contract) your pectoralis muscle—this varies tremendously from patient to patient and is not predictable.

Shifting of the implants to the side over time, widening the distance between the breasts—this also varies tremendously but is usually worse the thinner your tissues, the thicker your pectoralis, and/or the larger your implant.

Less control of upper breast fill, especially upper and toward the middle—the pressure of the pectoralis on the upper implant reduces control of fill in these areas.

Increased risk of upward displacement of the implant— this is related to the surgical techniques used. With optimal surgical technique, it is rare unless capsular contracture occurs and closes the lower pocket, pushing the implant upward.

Newer, dual-plane techniques provide virtually all of the tissue coverage benefits of muscle coverage, while drastically reducing or eliminating each of the trade- offs listed above for traditional retropectoral placement. Since the number one priority in breast augmentation is assuring optimal soft tissue coverage for a patient’s lifetime, minor trade-offs to achieve that goal are logical and essential to making good decisions.

By choosing the DUAL-PLANE pocket location (a combination of retromammary and retropectoral) instead of purely retropectoral or retromammary, at least 80 percent of the trade-offs listed above for partial retropectoral pockets are substantially reduced! You still get the upper coverage you need, but with dramatically fewer trade-offs.

Dual-Plane (Behind Pectoralis Muscle Above, Behind Breast Tissue Only Below) Placement—Benefits and Trade-offs

Realizing the importance of assuring adequate tissue coverage over all breast implants, but also wanting to reduce the trade-offs of traditional “behind muscle” placement, in April of 2001, in the journal of Plastic and Reconstructive Surgery, we published results of a clinical study of 426 patients whose implants were placed in the “dual-plane” position—a new pocket location that optimized coverage by placing implants beneath muscle in the upper breast, while minimizing the trade-offs of traditional “behind the muscle” placement by repositioning the lower border of the muscle and allowing the implant to lie in front of muscle, or behind breast tissue only, in the lower breast (Figures 6-10 and 6-11).


For the first time, surgeons can now offer patients the dual-plane pocket location (behind muscle in the upper breast and behind only breast tissue in the lower breast—optimizing tissue coverage while minimizing trade-offs).

The dual-plane pocket location has revolutionized the traditional approach to implant pocket location by assuring adequate coverage while optimizing implant-tissue relationships to assure patients fewer trade-offs.

Advantages of dual-plane placement

Maximal soft tissue coverage in the upper breast to reduce risks of implant edge visibility or visible traction rippling:

Allows the implant to optimally shape the breast without excessive pressure from the overlying pectoralis muscle in the lower breast,

Makes the location and shape of the fold beneath the breast more predictable and more accurate and allows the fold to form final contours earlier,

Reduces pain by decreasing tension on the muscle by the underlying implant,2

Allows over 95 percent of patients with dual-plane pockets to return to full normal activities in twenty four hours following augmentation and allows over 80 percent to be out to dinner the evening of their surgery,2,3

Allows patients to have muscle cover over their implants and not have more pain or a longer recovery as they formerly experienced with traditional behind-the-muscle placement,

Reduces pressure of the pectoralis muscle distorting

Breast shape when the muscle contracts,

Reduces pressure of the muscle that tends to displace the implants to the sides and widen the gap between the breasts.

Trade-offs of dual-plane placement

Slightly less thickness of muscle cover along the fold beneath the breast (and therefore not optimal for exceedingly thin patients who have a pinch thickness of skin and fat at the fold that is less than 0.5 cm (5mm).

No other trade-offs of dual-plane placement are scientifically documented at this time.

Feeling or Seeing an Implant Edge

If you place an implant under the pectoralis muscle, you have done all that is possible to prevent seeing the upper edge of the implant. What about feeling the implant? The muscle only covers the upper and middle portions of the implant, not the lower and outside portions. In the lower and outside portions of the breast, if you are very thin and can feel your ribs with your finger, you will almost certainly be able to feel the edge or shell of your implant, especially in the fold under the breast or at the outside of the breast. And don’t let anyone tell you that you won’t feel a smooth shell implant compared to a textured shell implant. If you’re thin, you’ll likely be able to feel either one. It you feel it, you feel it—you either do or you don’t, so fear of feeling an implant edge is not a good reason to avoid textured surface implants.

You can’t see the area under the fold of the breast (when standing), no matter how thin you are, so seeing an implant edge under the breast isn’t much of an issue.

At the outside part of the breast, if your skin envelope is extremely thin, you may be able to see an implant edge in certain body positions—no matter what implant, no matter how much skill a surgeon may possess! Why? Because you can’t change your tissues, and the only tissues covering the implant at the sides (laterally) are skin and fat. If skin and fat are thin, you may see or feel an edge of the implant! No way around it! If the surgeon tries to cover the lower, outer areas with muscle, you’ll have other trade-offs described previously.


If you are thin (and we’ll tell you how to measure it) and don’t want to see the upper edge of your implants, put them behind the pectoralis muscle.

If you want to avoid many of the trade-offs of traditional behind-the-muscle placement, select the dual-plane option, which combines the best of both worlds.

Your assessment of the relative benefits and trade-offs of placing implants above or below muscle: Nothing is perfect. You’ll have to accept some trade-offs with either location.

How thin is thin? That’s a tough question to answer! At what degree of thinness do risks of seeing an implant edge become significant? An even tougher question! The answers to these should not be—based on subjective opinions (yours or your surgeon’s) but should rely on objective measurements.


We use a simple, quantifiable pinch test to determine whether soft tissue coverage will be adequate with retromammary placement, or whether the tissues are so thin that retropectoral placement is a better option.You can do it yourself if you have a caliper. Isolate the breast tissue (parenchyma) by pinching to pull the breast tissue down and forward. Above the breast tissue, firmly pinch the skin and underlying fat, and measure the thickness with a caliper (Figure 6-12). If the thickness is greater than two centimeters (cm), your tissues are thick enough that retromammary or subfascial placement is an option, with minimal risks of seeing an implant edge. On the other hand, if the pinch thickness is two cm or less, you should definitely place your implants in the partial retropectoral position (traditional “behind the muscle”) or dual plane (under muscle in the upper breast, not under muscle in the lower breast).

If the pinch thickness of your tissues above your breast tissue is less than two cm, retromammary or subfascial placement of an implant is not the best option for best tissue coverage. If you put your implant under inadequate soft tissue cover, don’t be surprised and don’t complain when implant edges are visible and you develop an uncorrectable tissue deformity.

Don’t try to cheat on this! It truly isn’t worth it! With the innovations of the dual-plane pocket, you can optimize soft tissue cover in the upper breast and reduce the possible consequences of placing your implants under inadequate soft tissue cover: visible edges, visible traction rippling or wrinkling, visible implant shell—and the list goes on. If you are thin, measure your pinch thickness. If you measure less than two cm on the pinch test, and a surgeon recommends retromammary (behind breast tissue only, in front of muscle) placement, ask why. Also ask the surgeon about the risks listed above, and ask if the surgeon is familiar with the dual-plane pocket location that has all of the advantages of retromammary placement, while improving implant coverage in the upper breast. If a surgeon tells you that some “magic” type of implant can be placed only behind breast tissue and not be visible, be careful. Did the surgeon measure your tissue thickness? What kind of guarantee is the surgeon providing that you won’t see traction rippling when that implant weight pulls on thin overlying tissues? Providing optimal tissue coverage is always best, regardless of the type of implant.

One more time for emphasis:

1. If you are extremely thin (less than two cm pinch thickness above your breast), you should put the implant either dual plane (fewer trade-offs) or traditionally behind muscle (more trade-offs) to assure adequate tissue cover over the implant.

If you don’t, you run more risks of seeing the edges of your implant, seeing visible traction rippling, and risking other long-term problems that may be uncorrectable.

2. If you have adequate thickness of tissues (more than two cm pinch thickness above your breast), weigh the advantages and trade-offs listed above, and choose above or below the muscle based on your preferences and your surgeon’s recommendations.

Myths about Muscle . . .

You may hear some popular myths about muscle, so let’s mention them:


Under muscle prevents capsular contracture.

Not true. You can definitely develop a capsular contracture whether your implants are above or below muscle. Only with silicone-gel implants does over or under muscle make a significant difference.


Under muscle supports the implant better.

Not true. The theory here is that the attachments of the pectoralis muscle to the ribs (near the fold beneath the breast) act as a sling to support the implant. In fact, when these attachments are all left intact, they tend to cause two problems: Upward implant displacement (a high riding implant with excessive upper bulge) and more lateral (to the side) displacement of the implants, widening the gap between the breasts.


Over muscle is never good.

Not true. In fact, provided you have adequate soft tissue cover, over muscle allows your surgeon better control of breast shape and fill, but dual plane offers equal control of breast shape and better coverage in the upper breast.


Under muscle is never good.

Not true. If the pinch thickness of your tissues (above your breast tissue) is less than two cm, dual plane or under muscle is always better.


Figure 6-13 illustrates four commonly used incision locations for augmentation.


Based on twenty years of experience with all incision locations, I am convinced of the following:

Most patients worry far more about incision location before the surgery than they care after the surgery (provided they have a good result).

If an incision is on you, you will notice it!

If you have a beautiful breast, neither you nor anyone else will care where the incision is located.

Every patient thinks that the incision location she has is best.

Incision location is a common way that surgeons use to market their augmentation practice. If a surgeon touts the ‘X incision’” as unquestionably the best, and states, “I am the expert at the “X incision,” run the other way. No incision is best, and the likely message is that the surgeon doesn’t know how to do it any other way.

If a surgeon is experienced with all incision locations, the surgeon will offer you all options.

If you hear negative comments about an incision location from another patient or surgeon, it’s usually because neither has much experience with that incision location.

No incision location is always best. each location has advantages and trade-offs.

Every woman’s breasts, at some time in her life, are likely to acquire a blemish, a stretch mark or a biopsy scar. A well-executed incision scar is usually no more noticeable than these other blemishes, and if the breast is beautiful, who notices? Who cares?

Just because your friend had a certain incision doesn’t mean that incision location is best for you. In most cases, it doesn’t matter. A few, very rare breast deformities are best addressed through a certain incision, and when these deformities occur, we don’t hesitate to tell a patient, “With this specific breast deformity, a specific incision location gives us better control over your operation, and, hopefully, we’ll get a better result.” But in over 90 percent of patients that we see, we offer the patient a choice of incision locations. If a surgeon is experienced in all incisional approaches, the surgeon is less likely to recommend one location over another. Instead, the surgeon will give you a full range of options.

What’s really most important about incision location?

• How much control it gives your surgeon over your operation.

• How much it allows your surgeon to minimize trauma to your tissues.

• How far the incision location is from the implant pocket.

• How much normal tissue your surgeon must go through before getting to the implant pocket. The greater amount of normal tissue your surgeon has to go through, the more trauma, bleeding, pain, length of your recovery, and possible other complications you should expect.

• How many critical structures (mostly nerves and blood vessels) are located near the incision or on a path from the incision to the pocket.

Don’t form an opinion about incision location until you know about all the alternatives! Incision location is one of the LEAST important decisions you’ll make in augmentation. Each incision location has relative advantages and trade-offs.

What about Scars?

We’ve said it once, and we’ll say it again. No scar location is necessarily always better than another. Let’s examine some myths about scars:


For patients with minimal or no breast tissue, a scar under the breast isn’t a good choice.

Not necessarily. If the scar is properly positioned exactly in or very slightly above the crease beneath the breast, it will be minimally noticeable.

We’ve heard from more than one patient, “My boyfriend (a medical student on a medical fact finding mission, I’m sure ) said that he saw a scar on a topless dancer that was up on the breast, and it was terrible. I don’t want that incision.” The facts? Topless dancers have more inframammary incisions than any other incision. The reason the scar was more noticeable was that it was improperly located. If the scar is placed too high above the fold, it’s in an area where it is maximally stretched by the pressure of the implant. If it were kept exactly in the fold or very slightly above the fold, there’s less stretch, and the scar would be narrower. A popular misconception I’ve heard from surgeons is that inframammary scars should be placed well above the fold “so that it won’t show when she raises her arms in a bikini.” Fact is, less than 1 percent of a woman’s life is spent in a bikini. Fact is, a good scar exactly in the fold is far better than a widened scar that occurred because it was placed too far above the fold. If a surgeon is experienced in all incision locations, you can just choose! If you don’t like one (incision or surgeon), choose another!


One incision location is less noticeable than another.

Not true. It depends on the patient’s body position, who is looking, how long after the surgery (whether the scar is mature and faded), and the quality of the scar (largely dependent on each patient’s healing tendencies). What is always less noticeable is a better quality scar, regardless of its location.


A shorter scar is always better than a longer scar.

Not true. The quality of a scar is much more important than its length. A short, ugly scar is always more noticeable than a slightly longer, thin, faded scar. Experience has taught many surgeons that when you make an incision too short to minimize scar length, you often stretch that incision and “traumatize” the incision edges excessively during surgery. The scar does not heal as well, often stays redder longer and becomes wider. The result is a shorter scar, but also an uglier scar. A better quality scar, even if it is slightly longer, is far better than a short, ugly scar.


If you can put the incision off the breast in the armpit or the belly button, it’s always better.

Not true. We’ll cover specific advantages and trade-offs of each incision location later in this chapter, but there are definite trade-offs for both the axillary (armpit) and umbilical (belly button) approaches that may not appeal to some patients. Fact is, after surgery, scar location usually becomes a nonissue if the patient has an excellent result.


One scar location or another always preserves breast sensation better.

Not true. We formerly believed the axillary (armpit) incision preserved sensation better than other approaches, but after many more years’ experience, we don’t think that is necessarily true. The factors that most affect sensation are 1) surgical technique—the more the surgeon directly visualizes the anatomy and the less bleeding, the less risk of nerve compromise, and 2) the size of the implant—the larger the implant, the larger the pocket required, the more nerves are likely to be cut, and the more stretch the implant places on nerves; hence, the greater the chance you’ll lose more sensation.


Surgeons pick scar locations because they think one is best.

Not necessarily true. Surgeons usually pick scar locations based on their experience. If they have a lot of experience with different scar locations, they’ll offer you all options and discuss the trade-offs. If they’ve only done augmentations one way (or even the majority one way), that’s the scar location they will most likely suggest.


Located in the fold beneath the breast, the inframammary incision is the most widely used incision in augmentation and is the standard against which all other incision locations must be judged. The reasons? It gives the surgeon excellent access for augmentation in a wide range of breast types, offers better control of the operation in many instances, places the incision closest to the pocket compared to any other incision, requires the surgeon to go through less normal tissue compared to any other incision, has no critical adjacent structures (nerves or blood vessels), and is a “gold standard” that most surgeons learned during their residency training. More women have had (and continue to have) augmentation through an inframammary incision compared to all other incision locations combined.

The greatest advantage of an incision beneath the breast is the degree of control it allows the surgeon in a wide range of breast types and the fact that it minimizes damage to normal tissues and potential damage to adjacent critical structures.

More augmentation patients have had this incision location than all other incision locations combined.

The only trade-off of an inframammary incision is the presence of a scar in the fold beneath the breast.

The trade-off of the inframammary incision is the scar beneath the breast. Properly placed in a patient with normal healing, after the scar matures, the scar is less noticeable than the imprint of your bra on your skin when you remove your bra. A very small percentage of patients form less than optimal scars (more about that later). If you have formed very heavy scars on your chest area in the past (that did not improve with time), you may want to consider another incision location. No test can predict the quality of scar you will form. But for the vast majority of patients (well over 90 percent) , the inframammary scar location is an excellent choice.

So why would patients consider other incisions? In our experience, two main reasons:

1. If a patient has a “head trip” or preconceived negative ideas or concepts about an inframammary scar without understanding the trade-offs of other scar locations, or

2. If a patient has a personal friend or acquaintance who has had another incision approach and is happy with it. It’s human nature to think that if your friend is happy with a certain incision approach, you should choose that approach. In fact, that’s not true at all once you’re really informed.


This incision is placed around the edge (or just within) the areola, the pigmented skin surrounding the nipple. In most instances, the skin around the areola is thinner than the skin in the fold beneath the breast. There is some evidence that, all other things equal, thinner skin forms better scars than thicker skin. Some surgeons tout a periareolar (around the nipple-areola) scar as less visible than a scar beneath the breast. Is that true? Not necessarily. It depends on the quality of the scars in the two places, and that’s not totally predictable.

The greatest advantage of an incision around the areola is that it’s located in thinner skin that usually heals well.

The greatest trade-offs of a periareolar incision are increased trauma to breast tissue, increased exposure of the implant to bacteria normally found in the breast, and if you develop a bad scar, the scar is located in the most visible location on the breast.

A periareolar scar is located on the most visible area of the breast. As long as the scar is good—great. But if it’s not so good, and we don’t know who may form a bad scar, it’s not so great. It’s true that the skin of the areola area usually heals well, but if it does not, the less than optimal scar is noticeable every time you look at the nipple or areola.

Another stated advantage of the periareolar incision is that it’s easier for the surgeon to reach all parts of the breast from a central incision. Truth is, a skilled surgeon can reach all parts of the breast under direct vision by all incisions (with the exception of the belly button incision where a portion of the dissection is usually “blind”).

Trade-offs of the periareolar approach? If you have a very small areola, incision length can be inadequate without extending the incision onto breast skin which forms less optimal scars. When you cut skin, you cut nerves. When you cut nerves, most grow back, but not all, and not predictably. You might think that an incision around the areola would always make patients lose more sensation compared to other incisions, but it doesn’t! Why not? We don’t know! Probably because sensory loss is very unpredictable and may be more related to how the surgery is done (more about that later) or the size of the implant (the larger, the more stretch on nerves and potential sensory loss).

Every woman’s breast tissue contains bacteria. These bacteria live on the skin of healthy women and enter the breast through the nipple. They don’t usually cause infection because the body is accustomed to their presence in the breast. But put a large foreign object, your breast implant, in the area, and the bacteria can sometimes produce problems. When an implant is inserted through a periareolar incision, the breast implant is more directly exposed to breast tissue compared to other approaches. With more exposure to bacteria, you might think that infection rates would definitely be higher with this approach, but increased infection risk has not been scientifically documented. Even if an implant doesn’t get infected, bacteria around the implant are probably a major factor contributing to capsular contracture, so you might expect a higher risk of capsular contracture with a periareolar incision. Again, not scientifically confirmed, but in our practice, we’ve seen a slightly higher incidence of capsular contracture in patients who select the periareolar approach.

If you happen to form bad scars (and this can happen, regardless of your history of scars), the areola would not be an ideal place to have a bad scar. Bad scars are very rare in any location, but to date, we have no way of reliably predicting which patients will develop bad scars.


Placed in the deepest area of the armpit, the axillary incision is probably the least conspicuous of all augmentation incisions. Proper incision placement is critical. If placed in the highest portion of the armpit hollow, the scar is unnoticeable in virtually any body position. Even with arms fully raised, and even before the scar fades, losing its pink color, the incision looks like a normal crease. Once the scar is mature, it is almost impossible to detect in most patients, even with the arms raised. Another stated advantage of the axillary approach is better preservation of sensation in the breast. Actually, sensory preservation is quite variable and is more likely related to the type of dissection performed and the size of the implant.

The greatest advantage of an incision in the armpit is that its location makes it the least visible of all scars for augmentation.

The greatest trade-offs of axillary incisions are that a surgeon must be experienced, the operation time is usually slightly longer if the surgeon uses state-of-the-art techniques, and the patient must tolerate more potential nuisances in the armpit and upper arm areas postoperatively.

With older axillary techniques, after making the incision in the armpit, the surgeon used various types of blunt instruments to “blindly” create a pocket for the implant. The development of an instrument called an endoscope (Figure 6-14) allows surgeons to see inside the body on a television screen to more precisely control the operation. With the advent of modern endoscopic instrumentation, surgeons can see to precisely create the pocket for the implant instead of bluntly, blindly tearing tissues. This minimizes bleeding, maximizes accuracy, and shortens recovery. The longer operation time required for endoscopically assisted axillary augmentation is more than compensated by increased accuracy and control. A slightly longer operating time can mean more costs but should not increase any risks associated with the operation. Ask your surgeon.


The axillary approach using endoscopic instrumentation is technically more demanding of the surgeon compared to periareolar and inframammary approaches and is difficult for some surgeons to learn. If you are considering an axillary approach, be sure that your surgeon is experienced in endoscopic techniques and that the surgeon minimizes blunt, blind dissection.

The axillary approach traverses more normal tissue enroute to the pocket compared to the inframammary approach, and there are more critical structures (nerves and blood vessels) located in the armpit area compared to any other incision approach. Risk of injury to these critical structures is exceedingly small in the hands of an experienced surgeon, but nevertheless deserves consideration. Finally, minor nuisances around the incision (swelling, numbness, tiny bands of tissue beneath the skin, etc.) that can occur with any incision are usually somewhat more noticeable and bothersome to patients who have axillary incisions compared to other incision locations.

Regardless of a surgeon’s expertise, making an incision and tunnel through the armpit area requires that patients accept the fact that postoperatively, they may be dealing with one or more of the following:

• Enlarged lymph nodes in the armpit area,

• Fluid collections beneath the skin in the armpit area,

• Areas of numbness or tingling in the armpit and upper inner-arm areas,

• Potential permanent numbness in areas of the armpit or upper inner arm,

• A ridge where the incision is located for several weeks that requires care when shaving,

• Possible formation of small bands in the armpit area that may limit arm lifting movements. (These usually resolve spontaneously in a few weeks.)

All of these potential nuisances are manageable, and many patients experience few of these nuisances, but if you are considering an axillary incision approach, you should know that these nuisances are possible.

The axillary approach is not ideal for reoperations to correct postoperative complications or problems because it limits a surgeon’s direct vision and control. A second incision, usually inframammary, may be required to address postoperative problems or complications. Although it is technically possible to treat an excessively tight capsule (capsular contracture) via the axillary approach, the inframammary approach affords the surgeon much more control, more complete removal of capsule, and better control of bleeding, and it avoids traversing breast tissue (required with the periareolar approach).


Umbilicus is the medical term for your belly button. The incision for the umbilical approach is placed in and around the belly button. I use the terms “in” and “around” because, to some degree, the location of the incision depends on the size of the belly button. Most women’s belly buttons are small, and the incision required is one inch or more in length. The surgeon may not make the initial incision one inch, but the instruments required for the operation usually stretch the incision, and portions of the incision can sometimes extend outside the boundaries of the belly button.

The main advantage of the belly button incision is that it is located off the breast. The belly button incision sounds very acceptable to many women because they are familiar with other endoscopic procedures in the abdomen that use similar incisions, such as ligation of the fallopian tubes (tubal ligation). Actually, the incision required to insert a breast implant through the umbilicus is much larger than that required for many abdominal procedures.

The main advantage of an incision in and around the belly button is that the incision is located off the breast.

The main disadvantages of the umbilical incision compared to other incisions are:

• It offers the surgeon the least direct vision and control compared to other incisional locations and, therefore, the least predictable results.

• It is located farther from the breast, and more normal tissues must be traversed enroute to the implant pocket, increasing tissue trauma, potential pain and bleeding, and recovery time.

Access to the breast is created by bluntly pushing a one-inch diameter tube from the umbilicus to each breast through the tissues of the upper abdomen.

The pocket for the implant is developed by inserting an uninflated implant, blowing it up, then pushing it vigorously side to side to tear a pocket to receive the implant. the surgeon cannot see inside the pocket to create the most precise pocket with the least bleeding.

When the pocket is created by any method other than direct vision, the pocket is less accurate, bleeding is potentially increased, control is less, and tissue trauma is potentially greater.

Most surgeons who use the umbilical approach do not offer implant placement behind muscle. If you are thin, dual plane or traditional behind muscle is better long term.

Precise dual-plane pocket development and pectoralis muscle positioning is currently not an option if the umbilical approach is selected. No currently published studies indicate that patients having augmentation via the umbilical approach can routinely experience comparable recovery to the inframammary and axillary approaches we have published.2,3

The umbilical approach is not ideal for reoperations to correct postoperative complicatioins or problems because it limits a surgeon’s direct vision and control. A second incision, usually inframammary may be required to address postoperative problems or complications. Although it is technically possible to treat an excessively tight capsule (capsular contracture) via the umbilical approach, the inframammary approach affords the surgeon much more control of capsule removal, more complete removal of capsule, and better control of bleeding.

So why would anyone want to use this approach? It sounds good, until you really look at it objectively. Does this mean that you can’t get a good result through this incision? No. It just means you should be able to expect an even better result in the same patient through an axillary approach, with a faster recovery by avoiding additional tissue trauma when passing through the abdominal tissues and avoiding blunt, blind dissection. The armpit incision satisfies the advantage of moving the incision off the breast. The armpit incision is much closer to the breast, so much less normal tissue is traumatized getting to the breast, and the risk of depressions or troughs in the abdomen from bluntly pushing a large tube through the fat are avoided. From the armpit, the entire pocket can be created precisely and bloodlessly under direct vision for a more accurate, more controlled pocket with less bleeding. Your surgeon can also easily place the implant above or below muscle via the armpit, depending on your tissue needs.

Why would any surgeon want to use the umbilical approach? The umbilical approach allows some surgeons to differentiate themselves from other surgeons by advertising: “I can do it, and they don’t. Come to me.” The umbilical approach can be appealing from a marketing perspective, but I challenge any surgeon to debate me in a scientific forum on the logic of why it is really better. There is no scientific study that indicates that recovery (the best indicator of tissue trauma and bleeding) after umbilical augmentation can compare to the twenty-four hour return to normal activities we have confirmed for patients via inframammary, periareolar, and axillary approaches.2,4,5 We have many patients who are interested in umbilical augmentation—until they learn the facts and compare recovery to the other approaches. As long as surgeons are performing umbilical augmentations using blunt, blind dissection techniques, the umbilical approach offers no comparison to other approaches if precision, control, minimal tissue trauma and bleeding, and the most rapid recovery are objectives. In fairness, I hope that one day the umbilical approach will be able to offer the same level of control as other approaches and avoid unnecessarily traumatizing a normal area of the body (the abdomen) to get to the breast. When it can, and when a surgeon can create the pocket without using blunt, blind dissection, I’ll be happy to endorse the approach. We can always use more options—provided they make sense.


Much of the information you need about implant selection and size is included in Chapter 5. Some of the information is worth repeating, and you’ll need some new information that relates implant choices to the surgical choices previously discussed in this chapter.

The Implant Selection Process

A few guiding principles first:

Implant selection is ideally a team decision between you and your surgeon.

Assuring optimal soft tissue cover (selecting the pocket location, above or below muscle) is more important than implant selection.

When selecting implant shape (round or anatomic), think about the potential risk of shell folding and how that could affect the life of your implants.

Remember that all anatomic, or shaped, implants are not the same. Full-height anatomic implants with adequate fill to minimize risks of upper-shell collapse or folding while maintaining upper-breast fill are quite different compared to reduced-height or underfilled shaped implants.

When selecting implant size, the larger the implant, the more trade-offs and risks you’ll encounter, especially long term.

Incision location is less important than implant selection. both are less important compared to optimal tissue coverage.

Don’t worry too much right now about selecting your implant. Wait until you visit with surgeons and determine which surgeon best understands what you want and can best explain in detail your tissue characteristics and how they will affect your augmentation. Listen carefully to your surgeon’s implant recommendations and the reasons. Then make your decision.

Implant, Pocket Location, Implant, and Incision: Combinations That Are Available

The following table shows you that almost any implant can be put in almost any pocket location through almost any incision—provided you select an experienced, qualified surgeon. This table shows you the options that are currently available. A “yes” means that this is an accepted combination that has been scientifically confirmed and presented. A “no” means that although someone may be doing it, the jury is not in yet.


If anyone tells you that a combination labeled “yes” is not available, keep searching. I assure you that the options are there for you if you find a surgeon with experience in all approaches.


You’ll undoubtedly hear discussions about surgical techniques in your quest for the best breast. Most patients are not qualified to judge the details of surgical techniques. That’s what you’re paying your surgeon to do. But some basics are worth knowing.

There’s a difference between doing things because they’re easier and doing them because they are better.

Surgeons are human. some surgeons do things because they are easier and may even convince themselves that they’re better. It’s possible to achieve easier and better, but it requires surgeon commitment to increasing technical skills, time, and effort.

In surgery, better is usually more difficult until you learn more; then better is easier.

If I as a surgeon don’t know any better, I simply don’t know any better. that doesn’t mean that better doesn’t exist or can’t exist.

Surgical techniques evolve, and most get better with time. There’s always something new. The new things that are really better survive the test of time. The list of “new, better” implants and techniques that have disappeared is long, because time and scientific studies proved their weaknesses. Do all “better” surgical techniques become widely accepted? Absolutely not. In fact, a small minority prove their worth! When better things are more difficult, it almost always takes much longer for them to become widely accepted, sometimes until a new generation of surgeons comes along.

A good example is techniques used to create the pocket to receive a breast implant. Traditionally in surgery, sharp instruments, scalpels or scissors, were used to cut tissues. Problem is, when tissues are cut with sharp instruments, they bleed. Blood covers and stains adjacent tissues and obscures details that allow a surgeon to be more accurate. Blood loss, even if it is not life threatening, is messy, wastes time, and compromises accuracy. Blood soaks into your tissues and causes more inflammation, more pain, and a longer recovery time.


If a technique is easier or faster, I guarantee it will find its way into many surgeons’ bag of tricks. Blunt dissection, a technique used to create the pocket for the implant, is an example. Basically, a blunt dissector is an 18” round rod about the diameter of a ball point pen that is bent into a curve at one end (Figure 6-15). This instrument is used to tear, rather than precisely cut tissues. After the surgeon inserts the instrument, the remainder of the pocket dissection is “blind.” The surgeon is not looking inside the tissues as the instrument sweeps from side to side, tearing and separating tissues to create the pocket. During my residency training twenty-nine years ago, I was taught to use blunt dissection to create a pocket for a breast implant. Blunt and blind are not an optimal combination to create a pocket if the goal is to reduce tissue trauma and avoid bleeding. Blunt and blind have never been optimal, but blunt, blind dissection techniques still predominate today. It works, and it’s fast, but it’s also very traumatic to tissues and causes a lot of bleeding. Surely, there had to be a better way! I started searching, and I found the electrocautery. Scientific studies we have published1,2,5 now prove that precise electrocautery dissection techniques offer patients dramatically shortened recovery times—less tissue trauma, less bleeding, less pain, and hence a faster, easier recovery!

Electrocautery instruments use electrical current to cut tissue and to stop (coagulate) bleeding vessels (Figure 6-16). With electrocautery dissection, tissue cutting and blood vessel coagulation occur simultaneously! Incredible benefits! Dramatically less bleeding! The surgeon can see. The surgeon can be more accurate and spends less time stopping bleeding. Sound great? You bet! So everybody uses it to create pockets for implants, right? Wrong. A lot of surgeons still use blunt, blind dissection.


Blunt, or blunt and blind, dissection techniques for creating the implant pocket cause more tissue injury, tear tissues, create more bleeding, and result in a longer recovery time compared to state-of-the art electrocautery-dissection techniques.

During the seven years that I used blunt dissection, most of my patients (especially when the implant was placed beneath muscle) could not return to normal physical activities for at least ten to fourteen days. Today, over 95 percent of our patients (even with submuscular, dual-plane augmentations) return to normal activities within twenty-four hours!2 Why? No more blunt dissection! No more BLUNT AND BLIND dissection. More precise techniques using direct vision for control and to minimize bleeding and tissue trauma.

Compared to special, precise techniques of electrocautery dissection, creating a pocket by blunt dissection injures tissues more than precise electrocautery dissection, prolongs recovery, and carries a higher risk of complications such as bleeding and capsular contracture.

Having used all types of dissection, I can’t bring myself today to sharp dissect or blunt dissect a pocket! Thank goodness for progress! Our patients’ experience is totally different, with a return to normal activities that has previously been unthinkable. Think of the difference between a two-week recovery and, potentially, a one-day recovery! No surgeon can guarantee 100 percent of patients a one-day recovery, but avoiding blunt dissection dramatically shortens recovery times and allows over 95 percent of patients to return to normal activities within twenty-four hours.2,3

All electrocautery dissection techniques are not the same.

1. There are people who can play a piano, and there are concert masters. It’s not just whether a surgeon uses electrocautery dissection. It’s all about how that surgeon uses the instruments. Details of surgical technique make a massive difference in bleeding and tissue trauma and determine your recovery and your chances of many potential problems.

2. If you ask a surgeon if he or she uses electrocautery dissection, and they answer yes, the next question should be, when will I be able to return to full normal activities without any bandages, special bras, drains, or pain pills? Recovery will tell you just how well they can do it.

3. Electrocautery dissection has become a buzzword, but remember, it’s not whether a surgeon does it, it’s how the surgeon does it! Just because a surgeon uses the buzzword doesn’t necessarily mean that the surgeon optimally uses the instruments and techniques!

4. Asking about recovery will give you the answers you need. If you don’t have an overwhelming chance to return to normal activities within twenty-four hours, something isn’t optimal, no matter what a surgeon tells you or what buzzwords a surgeon uses.


Now you know about different surgical options. The next step is learning about the problems that can occur in breast augmentation, regardless of the options you choose.


1. Tebbetts, J. B. Dual plane (DP) breast augmentation: optimizing implant-soft tissue relationships in a wide range of breast types. Plast. Reconstr. Surg. 107: 1255, 2001.

2. Tebbetts, J. B. Achieving a predictable 24-hour return to normal activities after breast augmentation, part I: Refining practices using motion and time study principles. Plast. Reconstr. Surg. 109: 273-290, 2002.

3. Tebbetts, J. B. Achieving a predictable 24-hour return to normal activities after breast augmentation part I: Refining practices using motion and time study principles. Plast. Reconstr. Surg. 109: 293-305, 2002.

4. Tebbetts, J. B. Patient acceptance of adequately filled breast implants. Plast. Reconstr. Surg. 196(1): 139-147, 2000.

5. Tebbetts, J. B. Achieving a zero percent reoperation rate at 3 years in a 50 consecutive case augmentation mammaplasty PMA study. Plast. Reconstr. Surg. 118(6): 1453-57, 2006.

Back to Top
Chapter 7 →

The Best Breast

John B. Tebbetts, M.D., is a plastic surgeon in Dallas, Texas, specializing in primary breast augmentation. Dr. Tebbetts has revolutionized the landscape of breast implant surgery through his 24 Hour Recovery® and High Five Measurement® System.

As a premier plastic surgeon in Dallas, Dr. John Tebbetts has an unmatched track record among breast augmentation surgeons. Dr. Tebbetts developed the High Five Measurement® System which allows a woman’s body to choose breast implant size for her. His breast augmentation 24 Hour Recovery® has changed the way women expect to recover after breast augmentation. Dr. Tebbetts’ method means women can routinely have breast implant surgery in the morning and be out shopping the in afternoon.

Dr. John Tebbetts regularly produces breast augmentation video content. His practice blog, The Best Breast Blog, focuses on breast augmentation patient education. It is published weekly with the latest news about breast implants, both saline and silicone implants, and answers to the most frequently asked breast surgery related questions.

Dr. John Tebbetts is the only surgeon to have a proven zero percent reoperation rate in consecutive FDA PMA studies. View the results of his case studies and before and after breast implant photos on this website.

To have the best breast implants in Dallas, contact Dr. John B. Tebbetts’ office by calling (214)220-2712 or filling out a contact form.