Would you suggest an over or under the muscle implant with a Sientra textured silicone MP implant on a small 32C patient?

Based on your description of "adequate" existing breast tissue, the "need" to go below the muscle to reduce implant ripples or edge visibility is less, so technically, your surgeon is right--but that assumes all other things are equal about above or below the muscle placement. They are not!Most patients want "natural" look and feel (some actually want the high, tight, Baywatch coconut look, but they rarely understand that accompanying that look is the hardness of capsular contracture). Capsular contracture (CC) is definitely NOT something patients want, yet going above the muscles "bathes" your implants in bacteria from the breast ducts, and bacterial biofilm has been shown to be a source of CC. This is why Betadine or Adams triple antibiotic formula irrigations of breast pockets reduces (but does not eliminate) the risk of CC.So why go above the muscles at all? Most surgeons go below the muscles because that placement reduces implant rippling (saline for sure, but even silicone), edge of implant visibility, and capsular contracture. There are only a few "cons" of going below the muscle.Let's discard a few (false ones) right off the bat. Going below the muscles does NOT destroy the functionality or use of the muscles, though you have to retrain and restrengthen them after surgery. The muscles do not atrophy, and unless something goes seriously wrong during surgery (say by someone who is not a "real" plastic surgeon, is not certified by the ABPS,  and does not understand the anatomy properly), the strength and use of the muscles is preserved. Many plastic surgeons who do lots of breast augmentations have body builders or figure competitors among our patients. No problem.Going below the muscles does NOT require a longer or more painful recovery either. Careful surgery, precise dissection, meticulous hemostasis, and gentle tissue handling makes this (longer, difficult, and painful recovery) something seen only by those surgeons who use blunt dissection, drains, and Ace wraps or tight surgical bras after surgery (to stop bleeding, or drain it away, rather than carefully avoiding it and controlling it during surgery). So what are the actual downsides of below the muscle placement?The only real one is activation distortion. This is visible distortion of the implant when the pec major muscle is flexed, and it can occur on one or both sides. Sometimes this is minimal and barely noticeable, and other times it is quite a visible concern (especially if you are a body builder or figure competitor). Otherwise, most women do not actively flex their muscles while naked, and this is less of a concern if you understand that the tradeoff is a good one--avoiding the much bigger problem of capsular contracture, since CC usually requires surgical intervention.When activation distortion is severe, or enough of a cosmetic concern for patients to ask what can be done, often the only effective solution is to decide to go above the muscles, with all that accompanies that decision, including increased risk of visible edge, ripples, and CC. So, I applaud your surgeon for offering both options, though you did not say if enough information was given to help you weigh the pros and cons. I suspect not, since you are here online asking these (good) questions!Another issue that bears discussion is the use of textured implants below the muscles. If you ultimately decide to go above the muscles I would absolutely recommend textured, as this has been shown to reduce the incidence of CC, even though implant placement above the muscles increases the risk of CC. Do they cancel each other out? Maybe. Maybe not. (Hopefully) minimal flex distortion vs. CC requiring re-operation? Your call, but I know which way I would recommend.Why not consider smooth round cohesive silicone gel implants below the muscle, where you get the reduced risk of edge or ripple visibility, decreased risk of CC, and a soft, natural breast that actually flattens and drops to the side when you recline, just like natural large(r) breasts? Textured implants are designed to adhere to the tissues, and therefore do not move, drop, soften, or settle like smooth round silicone gel implants (Sientra makes great ones). Teardrop-shaped textured implants remain teardrop shaped in all positions, even when reclining, which in my books is decidedly UN-natural! Round textured implants are not position-sensitive, but do not move like smooth implants.Thus, I would recommend smooth round cohesive silicone gel implants placed below the muscles with proper inferomedial muscle fiber release (to reduce activation distortion), in the size and profile that best matches your breast base diameter. Your size and profile seem absolutely appropriate, and textured is not "wrong," just unnecessary IMHO, and perhaps ultimately slightly less natural. Again, if activation distortion is enough of a concern to warrant going above the muscle, then I would use the textured implants. But I think you will be better served by smooth below the muscles. Just don't flex naked! For more information you can click on the web reference link below for my Comprehensive Guide to Breast Augmentation, which has a large section on choosing implants. Best wishes! Dr. Tholen

Thank you for the question. There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”. The vast majority of breast implants placed in the "sub muscular" position are really being placed in the "dual plane" position ( partially sub muscular, partially sub glandular).
I think it is in the best interests of most patients seeking breast augmentation surgery to have implants placed in the “dual plane” or sub muscular position. This positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability of the implants (which may increase with time, weight loss, and/or post-pregnancy changes).

The submuscular positioning also tends to interfere with mammography less so than breast implants in the sub glandular position. The incidence of breast implant encapsulation (capsular contraction) is also decreased with implants placed in the sub muscular position.

On the other hand, sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants seen with flexion of the pectoralis major muscle) they can be seen with breast implants placed in the sub muscular position.

I hope this, and the attached link, helps. Best wishes.

I almost always place the implant under the muscle.  However, if you gave a fair amount of breast tissue that will cover the implant, it is fine to go above the muscle instead.