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

Question

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?

Larry S. Nichter, MD, MS, FACS · Answer

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

Marshall T. Partington, MD, FACS · Answer

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.

Vincent N. Zubowicz, MD · Answer

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.

Ryan Hoffman, MD · Answer

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.

Donovan Rosas, MD · Answer

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.

Jaime S. Schwartz, MD, FACS · Answer

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

Richard G. Reish, MD, FACS · Answer

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.  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

Harry T. Haramis, MD, FACS · Answer

Over the muscle looks more natural and maybgive more lift. It is also an easier recovery and useful in body builders. Higher fill gel implants can be used in thinner patients. Some increased risk with capsule contracture may result.

An exam and consultation with a plastic surgeon is recommended to discuss your options and expectations.

An exam and consultation with a plastic surgeon is recommended to discuss your options and expectations.

Nelson Castillo, MD · Answer

Thank you for sharing your excellent questions and congratulations on your desire to pursue a breast augmentation.  To answer your question, yes subglandular placement has an increased risk of rippling and the best candidates are those with enough natural breast tissue to avoid this possibility.  As the implant has less support subglandularly due to the absence of the pectoralis muscle it can lead to increased sagging risks, especially with larger implants.  Your submuscular risks are valid concerns but can be reduced by appropriate implant/patient selection and surgical technique.  Hope this helps.

Adolfo Sesto, MD · Answer

In my experience  I always  prefer  submuscular placement for a more natural look and to avoid displacement of the implants in time. Placing them just  under the gland will raise the   development of  displacement, rippling and hanging tissue.To avoid de double bubble in the submuscular placement is very important : 1. To choose  the right form of the implant to be place directly related to  the shape of the breast, and 2.  The PS will have to make some changes in the gland shape to avoid the sagging tissue over the implant that we call "double buble". So all depends on the technique, shape, and manipulation of the tissue.

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