There is data from around the 1990s to suggest that capsular contracture rate is statistically less likely if implants have more tissue coverage, and consequently, surgeons in the United States began to preferentially offer augmentation under the muscle. In years since we have learned that the most likely culprit of capsular contracture is a phenomenon known as biofilm; think of this as a mixture of microbes, skin cells, proteins, and other material that can get onto the implant. There is evidence that incisions in the fold are less likely to expose the implant to biofilm materials than incisions near the nipple, where bacteria may live. Additional techniques, like the use of an implant “funnel,” irrigation of the breast pocket with antibiotics/antiseptics, and other handling approaches, may also reduce the risk.
Placement under the muscle may allow for a flatter upper breast slope. However, the implant will be more likely to move in potentially unusual ways with the movement of the chest muscles— a phenomenon sometimes called “animation deformity.” This can be bothersome to some patients.
For this reason and some others, going under the muscle is NOT the way most surgeons in other countries approach augmentation. Some of these reasons include the fact that under-muscle augmentation can be more painful, has a higher risk of bleeding, and involves working on the rib cage. Additionally, the muscle may hold up the implant in a higher position, which may be disadvantageous in transgender patients who naturally have a lower nipple position. If the implant is held up by the muscle but the natural breast tissue should descend and sag (in larger breasted individuals or those with higher weights), there can be an imbalance of the breast mound leading to what we call a “waterfall” deformity.
Dr. Sayed will review these and other considerations for you during your consultation for MTF augmentation.