Should I Go Over or Under the Muscle?

I am currently a 34 B. I breast-fed 2 children.I used to be a full C up before my kids. I am 36 years old, 5 "4" and have mild sagging,loss of volume to my breasts. My nipple is still above crease. I am in great shape except for my empty breasts. I want to be a D cup and am opting for 450cc gels, moderate profile. Cant decide on the placement.

Doctor Answers (28)

Kind of Both

+3

A couple of observations.  It appears that you may have some mild breast ptosis and the upper portion of the breasts are empty.  I would recommend a dual plane placement.  This means the upper portion of the implant is beneath the muscle which gives you fullness but makes the edges of the implant less visible. The lower portion of the implant is covered by the breast tissue only.  This allows the nipple to move upward somewhat to help correct your ptosis without incisions for a lift.  Thanks for the picture.  

Dr. ES


Atlanta Plastic Surgeon
5.0 out of 5 stars 8 reviews

Over or under the muscle?

+2

I have to agree 100% with Dr. Stephenson. Your breasts demonstrate pseudoptosis, or bottoming out of the glandular tissue. The nipples, I think are OK, but really need the side view to knwo for sure. If you go with under the muscle, but do not use a dual plane 2 or 3 (probably a 3 in your case) technique, the glandular tissue will fall off the front of the impalnt like a "snoopy dog" deformity. The dual plane technique allows the impalnt to better fill out the lower pole of the breast.

You could also go above the muscle to fill out the lower breast, but you will pay a big price: You will have no muscle covering the implant which may make mammography more difficult, the implant will be more palpable and visible and feel and probably look less natural, especially as your tissue looks thin. Although there are those that will dispute me, I believe that there is no extra downtime for a submuscular dual plane technique than a subglandular (above the muscle) technique as I can easily obtain a 24 hour recovery with the former. In my opinion, there is no indication to use an above the muscle approach. I haven't placed an implant above the muscle in about ten years.

Mark D. Epstein, MD
Stony Brook Plastic Surgeon
5.0 out of 5 stars 151 reviews

I'd Recommend Under the Muscle

+2

Among the advantages of placing your implants under the muscle, the slope in the upper part of your chest will look more natural, with softer transition over the edges of the implant and less chance for rippling.

Careful re-draping of the muscle and breast around the implant in the lower part of your breast will produce a gratifying result with the size you are considering.

Paul C. Zwiebel, MD
Denver Plastic Surgeon
4.0 out of 5 stars 12 reviews

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Above or below the muscle

+2

Your photo is very helpful in answering this question. You have lost breast volume which is most apparent in the upper pole of the breast. The breast has fallen because the skin has lost its' ability to retract. Volume replacement is needed to restore a youthful shape and position of the breast. More volume is needed in the upper pole than the lower pole.
Placing an implant below the muscle adds another layer of your tissue to the upper pole of the breast in addition to the implant. The muscle will also compress the upper part of the implant slightly making the border of the implant less apparent. This yields a more natural appearance to the breast. As you continue to age the volume of the upper pole of the breast  will continue to decrease, this is what makes implants under the breast more apparent over time.

In addition to this the incidence of visible rippling and capsular contracture are higher in the subglandular (under the breast) position. 

I hope this was helpful 

Robert W. Kessler, MD, FACS
Corona Del Mar Plastic Surgeon
5.0 out of 5 stars 89 reviews

Breast Implants Over or Under the Muscle?

+1

Should breast implants go over the muscle or under the muscle - which is better?
An implant placed above the muscle is referred to as 'sub-mammary' (or 'sub-glandular'), while an implant placed under the muscle is referred to as 'sub-pectoral' (or 'sub-muscular'). The muscle in question is the pectoralis major. The term 'sub-pectoral' or 'sub-muscular' is somewhat misleading, as implants placed under the pec major are only partiallycovered by the muscle. The pec major covers the upper/medial half of the breast area, so a 'sub-pectoral' implant is truly subpectoral only in the upper and medial aspect of the augmented breast, while the lower and lateral aspect of the implant is actually in a sub-mammary position. Because sub-pectoral implants are, in reality, both sub-pectoral (upper/medial breast) and sub-mammary (lower/lateral breast), this placement has more recently been referred to as a 'dual plane' approach to breast augmentation.
There is also 'total submuscular' implant placement, in which the implant is positioned behind the pec major and the serratus anterior muscle, so that the entire implant surface is covered by muscle tissue. This is not commonly done for cosmetic breast augmentations, but has been used for breast reconstruction using breast implants.
There are a number of compelling reasons for selecting subpectoral placement over submammary placement. The most significant is that fact that radiologists have indicated that it is easier to image breast tissue by means of mammography when the implant is subpectoral. The pec major also provides an additional layer of tissue to conceal breast implants in the 'social aspect' of the breasts - that part that is easily visible in swimsuits and lower-cut clothing. Additionally, the pec major is quite effective at flattening the upper pole of a breast implant so that a natural slope for the upper aspect of the breast is created.
Implants placed on top of the pec major tend to look very convex in the upper pole. The breast begins quite 'abruptly' in the upper aspect of the chest, and the appearance is therefore distinctly unnatural. Submammary implants are also more likely to have visible implant folds and ripples in the cleavage area. Another consideration is the fact that there is some evidence which suggests that the risk of capsular contracture may be lower with subpectoral implant placement. Even if the risk of contracture is the same, a mild contracture tends to be less noticeable and therefore less of a problem for the patient when the implants are in a subpectoral position.
Submammary placement may produce a reasonable result for fuller figured patients with larger starting breast volumes, as the larger amount of natural subcutaneous fat and breast tissue helps to conceal the implant contours. The problem is that as breasts age, they tend to deflate - especially in the upper pole. So what was adequate implant coverage in the cleavage area at age 27 may be inadequate coverage at age 37, and implant folds and ripples gradually become visible. So subpectoral placement is the best choice for both the short and long term.
'Sub-fascial' breast augmentation is also possible. Fascia is the term for a sheet of connective tissue made of collagen, and the pec major has a fascial covering as most muscles do. Breast implants can be placed behind the pec major fascia only, rather than behind the entire muscle, however this approach is not widely used. The pec major fascia is a relatively thin layer of tissue, so it is not nearly as effective in concealing breast implants as the actual muscle itself. Partial sub-fascial placement can be useful in some breast augmentation revision surgeries, where variations in pec major origin or incorrect release of the pec major has resulted in significant distortion of breast appearance when the muscle contracts.   

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 41 reviews

Dual Plane Breast Augmentation For Glandular Ptosis

+1

Thank you for your question and photograph. An in person consultation is required for an accurate recommendation.

However I agree with the other doctors answering this question that you appear to have glandular ptosis which is breast gland below the inframammary crease but nipple areola above.

If this is the case then a biplanar sub-muscular breast augmentation should be possible without risking the "snoopy deformity".

Please consult plastic surgeons who are certified by the American Board of Plastic Surgery, experienced in cosmetic breast surgery and have an excellent reputation in your community. A careful and thorough consultation is required to help you make this important decision. You are fit and have normally shaped breasts and should be able to achieve an excellent result.

Brooke R. Seckel, MD, FACS
Boston Plastic Surgeon
4.5 out of 5 stars 31 reviews

Over or under muscle (breast aug)

+1

I would recommend under the muscle because more tissue will cover skin that looks a bit thin. You also may ptosis, which may require a lift, but it is hard to know without a side view.

Raj S. Ambay, MD
Tampa Plastic Surgeon
4.0 out of 5 stars 15 reviews

Placement of implant

+1

When I discuss about placement of the implants; on top vs behind the muscle, I tell my patient it depends on the amount of breast tissue you begin with.  If you have adequate amount of breast tissue for padding purposes, then you can have the implants placed on top of the muscle. If you do not, then placing the implant behind the muscle would be the better choice. In addition, I also look at other parameters, such as where is the upper breast border in reference to the nipple position as well as the inframmary crease. Remember, the implants have to sit above the inframmary crease. So, if your nipple sit high above the crease, then there is a possibility that you may still have some sagginess after the surgery, and that you may need a lift afterward. To answer your question about the implant placement, based on what I see, I feel you can have either one. You have to factor in all other parameters and the risks and complications of each placement to help guide you on your decision. I hope this helps. I am sorry, but there are a lot of parameters and factors that have to be taken into consideration.

Kim-Chi Vu, MD
Portland Plastic Surgeon
5.0 out of 5 stars 2 reviews

Breast augmentation submuscular or subglandular?

+1

Thank you for the question.

Generally implants should be placed in the partially submuscular position for the best results and avoidance of complications.  

Some general advice regarding breast implant sizing  may be helpful.
Much of the final “look” achieved after breast augmentation surgery  depends on several factors:

1. The initial shape, size (volume of breast tissue), symmetry of the patient's breasts. In general, the better the  preoperative breast appearance the more likely the breast augmentation “look” will be optimal.


2. The experience/skill level of the surgeon is important in determining the final outcome. For example, the accurate and gentle dissection of the breast implant pockets are critical in producing  long-term  well-placed breast implants. I personally think that these 2 factors are more important than any others, including type (saline or silicone)  or model (low/moderate/high profile)  of implant.

3. The type of implant used may  determine the final outcome, especially if the patient does not have significant covering breast or adipose tissue. For example, some surgeons feel that silicone implants have a more natural look and feel than saline implants because silicone gel has a texture that is similar to breast tissue. Each patient differs in the amount of breast tissue that they have.  If a patient has enough breast tissue to cover the implant, the final result will be similar when comparing saline implants versus silicone gel implants.  If a patient has very low body fat and/or very little breast tissue, the silicone gel implants may provide a more "natural" result.
On the other hand, saline implants have some advantages over silicone implants. Silicone implant ruptures are harder to detect. When saline implants rupture, they deflate and the results are seen almost immediately. When silicone implants rupture, the breast often looks and feels the same because the silicone gel may leak into surrounding areas of the breast without a visible difference.  Patients may need an MRI to diagnose a silicone gel rupture.   Saline implants are also less expensive than the silicone gel implants.
Other differences involve how the breast implants are filled. Saline implants are filled after they’re implanted, so saline implants require a smaller incision than prefilled silicone breast implants.
On May 10, 2000, the FDA granted approval of saline-filled breast implants manufactured by Mentor Corporation and McGhan Medical. To date, all other manufacturers’ saline-filled breast implants are considered investigational.
As of 2006, the FDA has approved the use of silicone gel implants manufactured by the Mentor Corporation and Allergan (formerly McGhan) for breast augmentation surgery for patients over the age of 22.


4. The size and model of breast implant used may  make a  significant difference in the final outcome. Therefore, it is very important to communicate your size goals with your surgeon.  In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural” or “C cup” or "fake looking" or "top heavy" means different things to different people and therefore prove unhelpful.
Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also be inaccurate.
I use  intraoperative sizers and place the patient in the upright position to evaluate breast size. Use of these sizers also allow me to select the breast implant profile (low, moderate, moderate plus, high-profile) that would most likely achieve the patient's goals. The patient's goal pictures are hanging on the wall, and allow for direct comparison.
I have found that this system is very helpful in improving the chances of achieving the patient's goals as consistently as possible.
By the way, the most common regret after this operation, is “I wish I was bigger”.



I hope this helps.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 727 reviews

Implant placement. Above or Under Muscle

+1

Most plastic surgeons prefer to place the implant under the pectoralis major muscle.  They tend to look more natural as there is more tissue on top of them.  they usually have a decreased rate of capsular contracture.  They typically have a decreased rate of sliding down the chest wall.  Each patient is different.  Each plastic surgeon is different.  Best to see three board certified plastic surgeons.  Bring photos of what you might like.  Please have reasonable expectations.  Together with the plastic surgeon, you will be able to make an informed decision.

Jeffrey Roth, MD
Las Vegas Plastic Surgeon
4.5 out of 5 stars 7 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.