Over vs under the muscle with slight sag? (Photos)

I have been to many consultations. Every dr says I do not need a lift but will most likely need one in the future. I would like my breast "lifted" as I've lost a lot of volume after BF. Am I better getting everything (breast aug and lift) now? Or should I place the implant over or under the muscle? I've heard conflicting advice. I feel after reading up on both they can both eventually lead to ball in a sock or the snoop dog effect. Which placement will give me better top pole fullness?

Doctor Answers 14

Over vs. Under the muscle

I highly suggest you have breast implants placed over the muscle. This will do a better job filling up the breast skin and will address the sagging. It is certainly possible for you to just get implants without a lift. In fact, I suggest you do that if you are terrified about the scars from a breast lift. You can always make the decision if you want more lift after the implants. The key thing is to have the implants placed on top of the muscle to give maximum lift as opposed to being blunted when placed under the muscle. Implants under the muscle will necessitate a lift.

Seattle Plastic Surgeon
4.8 out of 5 stars 80 reviews

Over vs under the muscle with slight sag?

Thank you for the question and pictures.

There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”.    I will try to outline some of the differences here;  you may find the attached link helpful as well.

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)  that can be seen with breast implants placed in these sub muscular position.

 I hope this, and the attached link, helps.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,488 reviews

Under the muscle

Hello and thank you for your question. There are several advantages and disadvantages to over vs under the muscle.  Under the muscle has the advantage of lower capsular contracture rates, less risk of rippling, and better visualization with future mammograms.  Most patients say that under the muscle also has a more natural look and feel.  A dual plane technique can provide added lift for you.  The size, shape, and profile of the implant is based on your desired breast size/shape, your chest wall measurements, and soft tissue quality.  This decision should be based on a detailed discussion with equal input from both you and your surgeon.  This entire surgery can be performed with a small incision technique.  Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.   The most important aspect is to find a surgeon you are comfortable with. I recommend that you seek consultation with a qualified board-certified plastic surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Richard G. Reish, MD
New York Plastic Surgeon
5.0 out of 5 stars 126 reviews

Over or under the muscle breast augmentation

An direct examination is necessary to be sure, but I would recommend based on your photos that you place the implants under the muscle with a periareolar lift. I believe that implants stay softer longer, and look more natural under the additional padding of the muscle, assist with evaluation of the breast tissue with mammograms. For that reason, you will not get the same amount of lift as over the muscle, and would benefit from a small lift.

Unfortunately, there is no perfect answer, and you will get multiple opinions. But most surgeons prefer under the muscle. Good luck.

Rick Rosen, MD
Norwalk Plastic Surgeon
5.0 out of 5 stars 22 reviews


Sorry to confuse you.

Yes, under muscle with ptosis causes snoop dog effect.

An implant with enough projection should give you a nice result without a lift, as long as the implant is ON Top of the muscle.

Richard Sadove, MD
Gainesville Plastic Surgeon
4.9 out of 5 stars 22 reviews

Over vs under the muscle with slight sag?

Thank you for your excellent question and photographs.  I would recommend placement of implants underneath the muscle based on your desired goal appearance stated in your narrative as well as it affords a more natural appearance, greater implant coverage, and trends towards fewer complications.  Hope that this helps.

Nelson Castillo, MD
Atlanta Plastic Surgeon
4.9 out of 5 stars 65 reviews

Over vs under the muscle breast implants with slight sag?

Thank you for your question photograph:

  1. In my opinion there are many advantages to having the breast implant placed underneath the chest muscle which will go a long way to avoiding the ball and socket appearance
  2. Your nipple appears to be above the inframammary crease or the fold under your breast.  Based on this a dual plane  submuscular breast augmentation should give you a nice result.
  3. Having the dual plane breast augmentation will avoid the scars associated with a breast lift.
  4. The implants will project the breast forward and you may not need a lift in the future since you're done having children.
  5. If eventually you decide to want a lift it can be done as a second procedure  which is the way combination lift and augmentations were done satisfactorily for many many years.
  6. For more information please read the link below:

Implant pocket

I prefer in most cases to place implants under the muscle.  It  does not look like you have any significant ptosis on your lateral views.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Go for the long-term fix

For the best long-term result, put the implant under the muscle.  The complication profile between submuscular and subglandular implants is TOTALLY different. An implant under the muscle reduces the risk of capsular contracture, makes the implant less visible and less palpable, and weighs less on the skin.  Using a "dual plane" technique, you would not need a lift.  Yes, you may need one in 10 years, but do your implants correctly now so that doesn't need to be fixed too!  Good luck

Robert S. Houser, DO
Columbus Plastic Surgeon
5.0 out of 5 stars 15 reviews

Is lift necessary?

I do not feel that you need a mastopexy. In terms of implant placement, it is true that placing the implants over the muscle would make for an easier recovery in the short run. However, because you don't have a lot of breast tissue, I would be concerned about rippling and capsular contracture.  Silicone or cohesive gel implants will produce a natural result.

Robert L. Kraft, MD, FACS
New York Plastic Surgeon
5.0 out of 5 stars 41 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.