"One of my friends who got breast implants last year just competed, and I didn't think her implants looked very good. Her surgeon told her that since she's a bodybuilder, the implants had to be above the muscle. Now that I'm planning to get mine, I'm not sure what to do-Above or below the muscle?"
Placement of breast implants in bodybuilding women presents a unique challenge for plastic surgeons and women bodybuilders. When I first started to do breast implant surgery in the early 1990s, silicone gel implants were only available for limited use, and as a result, nearly all of my early experience was with saline implants. After speaking with a few of my colleagues, it was obvious to me that these implants had a number of problems in women with very little breast tissue to cover them, and the position under the muscle helped to avoid most of these problems. Particularly troublesome were the problems related to visibility of the implant, including visible rippling and a clear visual border around the periphery of the implant. We've all seen women competitors on stage, who look like they've had a couple of implants glued to their chests and then painted over with some spray tan. As competitors, our goal on stage is to look like our bodies are shrink-wrapped in cellophane, so it's no surprise that implants placed over the muscle look like implants set on the chest and wrapped under cellophane as well. Placing the implants under the muscle, on the other hand, allows for an extra layer over the implant, which provides camouflage cover to the prosthesis. Indeed, submuscular placement of the implant provides the benefit of a "fuller" pectoralis muscle, since this is essentially a "pectoral augmentation." In fact, these "pec implants" are the only implants permitted by most bodybuilding organizations rules and regulations. Now gel implants are once again readily available, and in most women, these certainly look better when used over the muscle than saline implants. But in contest condition, the appearance will be just as disturbing as saline implants placed over the muscle.
What does this mean to you and your surgeon? First of all, you need to speak honestly with your surgeon to be sure that he or she understands your goals undergoing a breast enhancement procedure. Do you plan to compete? Do you live at low body fat percentages year-round? If the answer to these questions is yes, then you need to think carefully about implant position, and consider having them placed under the muscle.
"Last year, I underwent breast augmentation during my off-season with saline implants under the muscle. I love how they look when I'm relaxed, but when I flex my muscles, one of the implants goes up and one flattens out. What can I do?"
This is a problem I hear about now and then, and which I am particularly careful to try and avoid. I prefer a submuscular position for breast implants in my patients, since many of the women I care for engage in bodybuilding and more than a few compete. As I have said here before, implants over the muscle in those patients, particularly saline implants, can look very peculiar when their tissues are thin and tight in competition state. The procedure I do is referred to as a "dual-plane" positioning, which means that the upper half of the implant is under the muscle, and the lower half is just under fascia and breast tissue. This provides camouflage of the implant in those areas where the breast is visible in a bra or bathing suit, thereby making the implant less obvious. In placing the implant, I release the lower part of the pectoralis muscle along it's inferior border, and I release it all the way to it's attachment at the sternum. I try to do this exactly the same on both sides. In most patients, this release will result in the implant flattening slightly with pectoral contraction, pushing the implant down and out a little. Less commonly, in women with a very long muscle, the implant will ride up with pectoral contraction. If the implant is placed completely under the muscle, or in patients where the lower muscle isn't adequately released (such as patients who are augmented through a trans-axillary-armpit-approach), the implant will invariably migrate upwards with contraction. In some patient, like yourself, the muscle has been released on one side and not fully released on the other side. This can be challenging to correct, and it's important for your surgeon to try and identify the muscular attachments responsible for the superior displacement while you're awake, so that he or she can pinpoint the area to be addressed in order to release them and get your implants to do the same thing with muscle contraction. The alternative, of course, is to reposition them above the muscle in a new pocket, but this presents other concerns.
"I had my gyno fixed six months ago, but I feel like it's coming back. I haven't used anything since the surgery other than protein powder. It looks okay, but I can feel hard lumps under my nipples."
What you are describing following surgery is something that is commonly encountered in my patients, and something I tell them about before surgery. Namely, when we treat gynecomastia that is secondary to anabolic steroid use, as well as many other cases that may not be caused by steroids, we use a combination of liposuction and direct excision to remove all of the breast tissue that shouldn't be there, leaving an even layer of tissue over the underlying muscle. This includes a small glandular remnant that we must leave behind under the nipple-areola complex. In most patients, this tissue remnant is about 8 - 10 mm in thickness, though in very lean bodybuilders, I can often thin this down a little further. Removing this tissue entirely isn't possible, since it would leave a depression under the nipple and could cause compromise of the blood supply to the nipple-in other words, your nipple could die. So we leave a little bit of tissue, which could still respond to hormonal stimulation and grow back. Generally, however, in the early post-operative period, and in the absence of stimulation, you may still be aware of this small disc of tissue for several reasons. First, the glandular tissue in many bodybuilders is very dense, and the small remnant will also be palpable as a firm mass. Additionally, the remnant may swell following surgery for a variety of reasons, and this is often perceived as recurrence. In most of my patients, if the nodule remains swollen when the patient returns for his six month follow-up, I'll sometimes inject it with a corticosteroid to reduce the inflammation and scar process, and this usually shrinks it, presuming that it isn't recurrent gynecomastia. If the disc is palpable, but not visible, I usually won't do anything, since reducing it further could leave a nipple that appears hollowed out. The goal with gynecomastia correction is a chest that looks normal. Even with a perfect post-operative appearance, it may not feel normal.
Dr. Rick Silverman is a Boston-based plastic surgeon, whose practice is rooted in bodybuilding. One of his first patients in 1992 was a bodybuilder with gynecomastia, and his involvement with these patients eventually led him to the competitive stage, where he competed from 1996 to 2005, achieving professional status in the WNBF and competing in the masters level in the NPC. His practice focuses on providing optimal care for gynecomastia, breast enhancement, liposuction and other body contouring procedures, with a minimal interruption in your work-out regimen. He can answer your questions about bodybuilding and plastic surgery in the forum at http://forums.rxmuscle.com/showthread.php?t=34335
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