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Submammary breast enlargement


  The traditional, oldest method for a breast augmentation is through the submammary approach. Most of the plastic surgeons perform the breast augmentation through this approach and most of them are familiar only with this method.
 
 
The method of submammary approach with subglandular implant placement


Let’s look at the advantages and disadvantages one after the other!


The only real, concrete advantages are the tradition and the past, namely the force of habit.


DISADVANTAGES:

The structure of the skin
For a breast augmentation the submammary incision is the least favourable, since the skin here is the second thickest on our body after the back, therefore the expected scar is always more unfavourable than in the armpit, where the skin is thin and fine. It is also a great disadvantage, if the incision after the breast enlargement doesn’t precisely match the new fold under the breast, resulting in a scar even more unfavourable (wide, protruding, namely hypertrophic).

The submammary fold
After each breast augmentation the future submammary fold will be lower than it was before. As a matter of routine the professional plastic surgeon places the incision lower than the original fold (the lower margin of the glandular tissue). The question is, how much lower? This isn’t determined only by the dimensions of the planned implant, but also by the distension-expansion characteristics of the soft tissues of the patient which can be only estimated even with a 20 year routine! If someone doesn’t get this precisely, the scar will not be in the future submammary fold but below or above it, therefore it will be disadvantageous. At the axillary or periareolar approach this isn’t a matter, the scar simply won’t be there!

The healing
If for any reason a wound healing problem arises after a submammary breast enlargement, thus the wound is open and not sterile, the implant only a 0.5-1 centimeter underneath this wound can be hardly saved, the infection spreads to it early. If there is an infection or any problem of the wound in the armpit (this happened only twice in the last 15 years), it is very far away from the implant, and if the patient reports this in time, the implant can be kept safe.

 
 
 Scar in the submammary fold after our precisely planned operation at luckily optimal scaring disposition of the patient




  Operation performed somewhere else. Ideal scaring disposition, but unfavourable scar position, it is not in the submammary fold due to a mistake in planning.




Unfavourable submammary scars due to the planning mistakes of a breast augmentation and subsequent implant exchange – performed by another surgeon.



When is the submammary approach absolutely the best way?

- If we plan an implant exchange after a previous submammary breast enlargement, and the
   position of the incision (the position of the scar) was originally good
- If an implant exchange can not be performed safely from the axillary approach, primarily
   because of an advanced capsulare contracture
- If the patient has an extremely thick, strong pectoral muscle developed by body-building,
   therefore a submuscular implant placement is not advisable, and only an anatomical
   implant comes into question because of the very thick muscle


When is the submammary approach the worst choice?

At a very thin patient with a small glandular tissue, when the submammary fold is the least determinable or visible, where the skin and the muscles are tight and the ribcage is also thin.

If because of the constitutional circumstances a simultaneous mastopexy is necessary, or it is expected that the patient will have a sagging because of a later pregnancy and breast feeding after the first breast enlargement. In the latter case the submammary scar will not be “needed”, meaning if the patient needs a mastopexy after all, she will have scars everywhere, even there where it shouldn’t be!

If tubular breasts must be enlarged, which means that the nipples look downwards and the distance between the areola margin and the submammary fold is less than 4-5 cm, therefore it is more difficult to estimate the future submammary fold position.

We consider it very important, that a patient should consult more plastic surgeons before a breast augmentation (or implant exchange), asking about the operation method, planned approach, characteristics of the suggested implants. She should decide only after this, we do not dread the comparison!
 
Dr. Tibor Balajthy
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