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One of the commonest questions that I get asked, and it gives rise to a great amount of confusion, is the plane in which a breast implant is placed.


Hopefully this short article can provide you with some information to help you understand a decision making process.


Firstly, I want you to imagine that an implant is a golf ball. If you place a golf ball under a sheet, it will have a very obvious appearance, with a very distinct junction where it sits on the bed. Now imagine that the same golf ball is placed under a doona. Obviously it will look very different, and it will hardly be visible at all.

Placement of breast implants is very similar. In thin people (“sheets”) there is very little soft tissue to cover the implant, and the junction between the implant and the chest wall is very obvious – a look most patients want to avoid. In these individuals, an implant might need to be covered in some muscle, which essentially converts a “sheet” into a “doona”.

However, if a person is carrying some extra weight (“doona”), placing an implant behind the muscle is effectively adding a second “”doona” on to what is already and adequately padded bed! Like the story of the princess and the pea, the shape of the implant will be completely lost in the extra covering, and consequently the breast will not have a good appearance.


The decision that Dr. Brown has to make, is where does a “doona” stop and a “sheet” start? He examined this issue in a 2012 peer reviewed publication by examining data from 329 patients following breast augmentation. When you have your initial consultation with Dr. Brown, he will measure the thickness of tissue over your breast with a series of measurements, including a body fat calliper. His data suggests that a “sheet” begins and a “doona” stops when there is less than 20mm of soft tissue measureable with the calliper. A subsequent piece of research by Dr. Brown has discovered that individuals who have a body mass index (BMI) in the normal range (19-25) statistically have the same amount of soft tissue at the side of the breast bone, and that it is always at least 20mm.

Why not simply put all implants behind the muscle in thin people?


Placement of an implant behind the pectoralis major muscle is not a procedure that should be undertaken lightly. It involves dividing the muscle from the sternum over the lower portion to allow it to drape over the implant. In athletic women, this procedure has been shown to reduce the performance of certain exercises such as push ups, bench press and inclined flies. The procedure is also associated with a prolonged recovery before return to normal exercise.


Even in woman who only undertake moderate exercise, the constant action of the pectoralis muscle tends to cause it to displace over time, with one author suggesting that majority of sub muscular implants require revision by 7 years post surgery.


Most women notice that when they move their shoulders following sub muscular breast augmentation, their breast move and distort to a varying degree. This is called animation, and is a normal, but often unwanted consequence of placing an implant under the pectoral muscle.



For lean individuals, Dr. Brown has been at the forefront of publishing data concerning placement of the implant in the sub-fascial plane. His 2012 publication on the subject was recognised by his colleagues in Australasia as the best peer reviewed cosmetic surgery paper in the Aesthetic Surgery Journal, and was awarded the prestigious ISAPS Prize. It represents a comprehensive experience of one of the largest series of sub fascial breast augmentations in the world.


The pectoral fascia is a very thin fibrous layer that covers the part of the muscle which contracts. If you take the time to look at a steak, it is the white glistening layer that covers the meaty fibres. Whilst the layer is very thin, it is immensely strong and inelastic such that placing an implant behind this fascial layer will compress the upper portion of the device and blunt the junction between the implant and the chest wall. By using this type of sub-fascial breast augmentation, Dr. Brown in happy to undertake breast augmentation in very lean individuals where there is only 12mm of soft tissue measureable by the calliper. His publications and ongoing audits have demonstrated that using this assessment system for deciding how an implant should be placed provides a very high degree of patient satisfaction, with low complication rates (rippling in <4%, revision surgery in 0.25%).



So in response to the question “does Dr. Brown place implants in front of or behind the muscle?” the answer is “it depends on the individual undergoing surgery, there body measurements and lifestyle.” For that reason, we recommend a consultation with Dr. Brown so he can advise which procedure is the correct choice for you





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