Over the Muscle Breast Implant Placement Best for Sagging from Nursing?

There are many options when considering breast augmentation...silicone, saline; smooth, textured; round, anatomical; moderate profile, high profile; on top of the muscle, completely under the muscle, or partially under the muscle; lift, no lift etc.
Generally speaking, if a patient has a somewhat droopy or ptotic breast and would like to avoid additional scars for a breast lift, they will be better served by having their implants placed partially under the muscle (dual plane) or on top of the muscle. Having said this, patients who have lost weight or have had their breast tissue atrophy following nursing will have a much more naturally feeling breast with silicone implants versus saline implants. As you can see, there are many options.
Meet with a few plastic surgeons to get a better understanding of what is best for you. A nice place to find board certified plastic surgeons is at www.surgery.org, the website for The American Society for Aesthetic Plastic Surgery.

Thank you for your question.  One of the biggest misconceptions when it comes to breast augmentation procedures is that an implant will help to lift a patients breasts.  The truth is that implants add volume.  They do not elevate the nipple aerolar complex or tighten and reshape the breasts as a breast lift procedure would allow.  I believe that implants in the sub-glandular position is a mistake because it will ultimately leave patients with a 'rock in sock' breast appearance.  Sub-glandular implants also are associated with a higher risk of capsular contracture, palpable implants, and make breast imaging studies, such as mammograms, more difficult.  In my experience, patients are happier when the implants are placed in the sub-muscular position and these patients do much better long term.  I hope this helps and best of luck!

Hello! Thank you for your question! Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts. Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years. In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance. Your breast width is the most important measurement. Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant. This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape. Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width. Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later. Very slightly less tissue may be visualized with subglandular implants, but not very significant.Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle). Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each. In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome. A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles. Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions. As you see, there are a few factors to decide upon for incision, placement, and implant type/size. Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits. Hope that this helps! Best wishes for a wonderful result!

Generally speaking, submuscular placement (dual plane) is more common than sub glandular because the chest muscle covers the majority of the implant, acting like extra padding to make the implant less visible and 'feel-able'. It also makes mammograms easier to read. What your surgeon recommended is probably suitable for you.

I prefer submuscular placement for many reasons.  The lifting can be achieved with either, if you are appropriately skilled.  Find the surgeon with the best pictures, most experience, and best reviews.

It’s not unusual for women to
have both breast hypoplasia and breast sag following pregnancy. Formulation of
a treatment plan for this condition can be very difficult, in the absence of
pre-operative pictures and a physical examination.

 

When sag is severe, it must
be addressed to optimize the surgical result. In some cases, placing the
implant on top of the pectoralis muscles can provide a solution for this
problem. In the majority of cases, placement of implant beneath the muscles in
combination with breast lift surgery is indicated.

 

Depending on the specifics of
your breast exam, both under and over the muscle approaches may have
advantages. The choice in your case will depend upon the specifics of your
anatomy and your personal aesthetic goals.

Both of your surgeons might be right.  Women with modest droopiness can often times have this camouflaged with a breast augmentation (presuming they want to be bigger).  In this case, implant placement above the muscle is aesthetically surperior.

If, on the other hand, an implant is placed and a mastopexy (breast lift) is done concurrently, the implant should go behind the muscle.  This has to do with blood supply to the breast and areola.  Placing the implant above the muscle in this circumstance would be risky.

beccatj, As you know, breast implants can be placed under or over the muscle. Both of your surgeons are correct. Placing them over the muscle (under the breast tissue only) will allow the implant to "fill" up the the missing volume in your skin and may avoid the lift. However, long term, the skin may stretch from the weight of the implant an you may likely need a lift down the road.
Placing the implants under the muscle gives an extra layer of support to the implant. If there is a moderate about of ptosis (drooping of the breasts tissue), then you may need a lift to center the breast tissue over the implant. However, the results will likely look more natural, especially in the upper pole with the implant under the muscle. So, you could go either way and get nice results. Good luck with your surgery.

You could have 2 or 3 more consultations and get as many different opinions. In gneral, going under improves the contour along the upper portion of the breast and may help it to look more natural. Some believe that implants are less prone to capsular contracture under the muscle. Disadvantages are that the breast may distort when you are being physically active and the muscle flexes, and that the muscle may tend to push the implants too far apart or down.
So, it is a matter of the surgeon's judgment and experience. Just to make it more complicated for you, there is an option called "subfascial" which provides support like going under the muscle but no risk of flexion distortion (called "animation deformity.") A variation of this is to split the muscle instead of cutting it and use just the upper portion for implant coverage. This is the technique I use in women who are thin and/or athletic, so that they get a natural contour but without the risk of animation deformity.

I hate to add to your confusion, but the truth is that there is more than one way to achieve a nice result from a breast augmentation. It really comes down to the judgement of the surgeon based on his experience, your anatomy, and your goals from the procedure.
In general, I find that while most women will do very well with the implant placed underneath the muscle, if a woman has a small amount of breast droop or ptosis, the implant can be placed above the muscle to create a very natural result without requiring the incisions of a breast lift; in these cases, I recommend cohesive gel silicone implants to acheive the most natural feel.
I would consult with Board Certified Plastic Surgeons in your area, listen to their recommendations, and then go with your gut-- I am sure you will end up with a terrific result!
Dr. S