Submuscular vs subglandular breast animation and cosmetic concerns? (Photos)

I'm concerned about implant placement, my biggest reason being animation. I want my breast to move like natural breast. Is there more risk of rippling with subgland placement? (In my case?) I've been told I can do either, I am a B was a D, goal C I've read about a ball in a sock look happening from subgland because it can cause early sagging is this true? Submusc. Concerns: snoopy breast, double bubble, bottoming out. What is the higher risk w/ each method? What other deformities can occur?

Doctor Answers 16

Submuscular vs subglandular

Submuscular placement may be more uncomfortable the first few days following surgery. The possible benefits of submuscular placement are that it may result in less palpable implants, less capsular contracture, and it will make it easier to image the breast with mammography. The appearance may be more “natural” for patients who are very thin. Subglandular placement may make your surgery andrecovery shorter and you may have less discomfort. This placement may provide a slight “lift”. Subglandular placement may result in more palpable implants, more capsular contracture and more difficult imaging of the breast with mammography. This placement is often recommended for those patients with sagging, but do not want a breast lift (mastopexy) and for tubular breast deformity

Dr Kayser

Thank you for your question which seems to be related you your previous one. Implants are typically placed under the muscle to allow better coverage in the cleavage areas and upper portion of the breasts. It is also thought to help decrease capsular contracture. Finally there is the potential advantage to having less interference than an implant placed above the muscle when it comes to mammograms. The disadvantage would be an increase the gap between the breasts and also the potential for distortion of the implant when the muscle contracts which is referred to animation deformity. This can be particularly disturbing in patients who are lean and athletic.

Implants placed above the muscle are generally reserved for patients who might have adequate coverage in order to decrease the risk of both visible and palpable rippling or in women who may have breast ptosis which would place the implant significantly lower than Where adequate muscle coveragevwould exist. However, this would completely eliminate a problem with the animation deformity and also improve the gap between the breasts. There is some data to suggest that if an implant is placed above the muscle, the use of a textured device can help decrease the capsular contracture risk. Both approaches place the implant beneath the breast gland itself so breast feeding is no affected with either method.

The most current approach is to have implants placed above the muscle in combination with fat transfer. This would allow the placement of fat from one part of the body to the areas of the breast that may not have as much coverage. Fat is natural and once integrated into the tissue, has the potential to last a lifetime. Finally it is also an approach which allows filling up the contours of the breast that an implant simply cannot reach.

In any case I would certainly recommend a consultation with a board certified plastic surgeon who is experienced in all types of breast surgery and fat transfer as this can be very technique dependent. Please view the attached video which describes a patient who has had this exact situation where implants were actually transferred from behind the muscle to above the muscle with the addition of fat. I hope this helps and have a wonderful day. Dr. Kayser - Detroit

Melek Kayser, MD
Detroit Plastic Surgeon
4.9 out of 5 stars 31 reviews

Implant Position: Pros and Cons

One of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons have a preference, the truth is that each approach has pros and cons:

Subglandular Augmentation (Under the Gland/Over the Muscle):

 ·      Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also relatively faster when compared to subpectoral augmentation. 

·      Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection). 

·      Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space. This can be mitigated by the use of a textured device. 

·      Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.

 

Subpectoral Augmentation:

 ·      Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade” or ride up. The upper hemisphere of the implant sits underneath the muscle (dual plane), while the lower pole sits below the breast tissue. This muscle release contributes much of the discomfort encountered postoperatively by patients. 

·      Subpectoral implants have a lower rate of capsular contracture. This mitigates the need for a textured device.  

·      Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.

·      The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

  Each approach has both costs and benefits. Patients are unique and so too is each operative plan. There is no replacement for an in person exam. A potential augmentation candidate may be better suited for one approach or the other.  As always, your board certified plastic surgeon can help guide you in your decision making process.

Donovan Rosas, MD
Westchester Plastic Surgeon
5.0 out of 5 stars 7 reviews

Submuscular vs subglandular

You need to have a full discussion with a board-certified plastic surgeon. I perform almost all my augmentations over the muscle to avoid breast animation. With the new highly cross-linked silicone gel implants rippling is minimized. I prefer a textured surface on the implants. Without your pictures it's hard to judge what I would recommend for you. However these general principles apply.

Bottoming out is more common with sub muscular implants.

The incidence of contour irregularities when silicone gel implants are placed is about the same above or below the muscle. Some muscular implants are influenced by the vector of force generated when that muscle is exercise. In some patients this can push the implant and inferior direction causing bottoming out.

Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon
4.9 out of 5 stars 32 reviews

Sub-muscular vs. subglandular placement

You have some very knowledgeable questions. The truth is that there is a give and take with each procedure. A consultation with a board certified plastic surgeon is the best way to figure out which procedure is the right one for you.

It is hard to answer those questions without seeing you in person.

Ryan Hoffman, MD
Philadelphia Plastic Surgeon
5.0 out of 5 stars 33 reviews

Breast Implants/Breast Augmentation/Anatomic Gummy Bear Implants/ Silicone Implants/Breast Implant Revision Surgery

I appreciate your question.

The best way to determine implant size is based on chest wall measurements that fit your body.  Once we determine that we can choose the profile based on what you want or need to achieve.  

Implants under the muscle, there is less risk of capsular contracture.  Anatomic implants tend to give a more natural shape with more nipple projection.

The best way to assess and give true advice would be an in-person exam.  Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.

Best of luck!

Dr. Schwartz

Board Certified Plastic Surgeon

Director-Beverly Hills Breast and Body Institute

#RealSelf100Surgeon

#RealSelfCORESurgeon

Breast augmentation and pockets

Each pocket position has pluses and minuses.  Under the muscle one may get an animation deformity in some situations, but have a lower risk of rippling or implant visibility than above the  muscle. Best to review in person. Good luck.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Great question about implant placement

Where to put a breast implant is a source of much debate and the answer will vary based on where you are in the world.  In the US, submuscular (or dual plane where the implant is covered by muscle superiorly and breast and soft tissue inferiorly) is the go to operation.  In central and south america, you will find more proponents of subfascial placement.  In certain parts of Europe, subglandular placement of textured, anatomic devices is viewed favorably.  There is no "right" answer and what is best for you depends on your tissues, desired size, the surgeon you choose, etc.  

A subglandular augmentation is more prone to capsular contracture.  The frequency of conjecture is lowered with a textured device.  If you are skinny, this is a bad idea due to increased palpability, etc.  That being said, I have seen excellent and durable results when executed in the right patient.  During my training, I remember seeing a patient who had an augmentation by my chairman.  It was subglandular with a smooth device, and she had a durable, pristine result 20 years later!  So, it all depends.  The subglandular does look more natural (at least in the short term), and can lift the skin in the context of laxity.  

Surgeons often state that subglandular augs are not as durable in terms of wear and tear of the soft tissues.  This is not completely true.  A dual plane procedure leaves the implant exposed to breast and soft tissues inferiorly just like a subglandular implant.  Due to gravity, this is the primary vector of force exerted on the tissues.  Furthermore, the compressive action of the pectoralis major muscle squeezes the implant downwards and outwards adding further potential stress to the tissues.  This can often lead to what is termed as a "down and out" deformity that can show up years later and patient's with thin tissues and larger implants are vulnerable to this.  A textured device can mitigate against this in either approach.

An alternative (and superior approach in the eyes of some surgeons) is the subfascial approach where the fascia on top of the pec muscle is lifted up.  Proponents believe it was the advantages of both subglandular and submuscular approaches with good soft tissue redraping, lift and comparable rates of capsular contracture.   I do not ascribe to this approach but board certified surgeons I know and trust think subfascial augmentation is SOTA.  

For me, a well executed dual plane procedure is the way to go.  Just make sure you choose an appropriate size.  Going to big will lead to trouble regardless of the plane of placement.  Good luck.       

Breast animation and cosmetic concerns.

What you mention are very important concerns for all of us who perform breast augmentation. There is no one perfect solution for all, and subglandular augmentation might be the right choice for you. We simply don't have the space to cover all as there are books on the subject and so many implants to consider. If you have been told you can do either you might consider another opinion.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.1 out of 5 stars 40 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.