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

I had 2 more consultations for breast augmentation today, and now I'm even more confused. I'm a 36C (deflated C) and do have a small amount of sagging from nursing. One of the doctors I went to today said that he wanted to go under the muscle, and that I didn't need a lift. The other one (board certified plastic surgeon) said that he wanted to go over the muscle and use an HP implant because I have some drooping, but not enough for a lift.

What is the major difference between going over and under the muscle? Will going over really give me upper pole fullness? I had always heard that going under was best, but I was told that because I have a good amount of breast tissue, going under wouldn't look right, and going over would give me a bit of a lift as well. I liked both of the doctors today, and am so excited about getting a breast augmentation. I just have to figure out whether to go over or under. Please help!

Doctor Answers 32

Options with regards to the muscle

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While it would be difficult for someone to tell you whether you would be best suited to have implants placed over or under the muscle without seeing you, there are a few things to consider that may help you. Currently, more implants are being place under the muscle, than over the muscle if you look at breast augmentations across the board. And, because of this, many people have heard that it is better to go under the muscle. This is, in fact, true for many women. However, some women are good candidates to have the implants placed on top of the muscle. Factors that wll allow a good result when going on top of the muscle include, a moderate amount of breast tissue, the use of silicone implants, and some tissue looseness without true sagging.

One of the major advantages of placing the implants under the muscle is how the upper pole of the breast will look in women with very little breast tissue. In these women, the muscle helps give a better slope to this area, and makes it look less like there is an implant. When you have a moderate amount of breast tissue, as in a B or C cup, the breast tissue itself will give the coverage needed to look natural, and the advantage of going under the muscle is not necessarily needed.

Silicone implants generally do better on top of the muscle than saline implants. This is not to say that saline implants cannot be placed under the muscle, becaue they can be. However, silicone, due to its compliance and softness, will tend to do a bit better than saline on top of the muscle. (Once again, the more breast tissue present, the better saline implants will look and feel on top of the muscle.)

The last issue is tissue looseness. It is a mistake to think that placing an implant on top of the muscle will be a replacement for a breast lift. If you have sagging, a breast lift will almost always be needed for the best results. But if there is some looseness to the tissue without sagging, going on top of the muscle may give a bit better filing of the soft tissue envelope. However, this may mean that the implants are slightly lower, and there may be less fullness of the upper pole when you are not wearing a bra.

Two other things to consider. For most women, the recovery will be a little quicker when the implants are on top of the muscle. And, there will be no distortion of the shape the breast on contraction of the chest musculature if the implants are on top. With submuscular implants, there can be a bit of change in the shape of the breast upon actively contracting the pectoralis muscle. This goes away wheh the muscle is relaxed. Usually this is mild and not a problem. However, there are few women in whom this distortion is pronounced and troublesome. Such distortion will not happen when the implants are on top of the muscle.

Hopefully these considerations will help you in your decision making. However, you will have to decide what makes the most sense for you. My best advice is to make sure you are talking to board cerified plastic surgeons (ASPS members) and ask them specific questions about why they favor one approach over the other. You may need to visit them both again. Ultimately you are best off going for the surgeon with whom you commumicate best, and in whom you have the most confidence.

Good luck!

Knoxville Plastic Surgeon
4.9 out of 5 stars 111 reviews

Not every patient benefits from one technique.

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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.

Sanjay Grover, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 245 reviews

Breast implants should be placed over the muscle to correct slight sagging

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To beccatj,

Hi! Several points:

1) Implants over the pectoral muscle will definitely correct sagging much better than under the muscle. Over the muscle, the implants can "re-inflate' the breast skin much better. In fact, implants under the muscle with sagging can create a deformity.

2) Implants alone (in any position) will only correct a little sagging. If you have a positive "pencil test" (put a pencil under your breast, and if it stays there, it is positive), you may also need a slight lift, specially if you want upper pole fullness. I often do a lift around the nipple together with implants.

3) Whether you use high profile implants should depend only on the width of the base of your breasts.

4) Be careful not to get implants that are too large. You are a C already. Do you really want to be a DD? Very large implants have more complications and don't age well.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Either breast implant placement can work well

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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

Shahram Salemy, MD, FACS
Seattle Plastic Surgeon
4.9 out of 5 stars 155 reviews

Let's clarify this please

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IMPLANTS ADD VOLUME - THEY DON'T LIFT THE BREAST. It has been a common misconception that placing an implant above the muscle will give the patient a lift - it does not. Eventually, you will potentially end up with a "ball in sock" bottom heavy matronly look with an implant above the muscle. Mammograms are more impaired, capsular contracture rates are probably also higher above the muscle, the result looks more edgy in some patients and the implants are more easily palpable above the muscle. Using a big high profile implant to gather up loose skin won't make you happy unless that final "look" of the high profile implant and the large size it generates is what you want.

A LIFT ELEVATES THE NIPPLE AREOLA AND TIGHTENS AND RESHAPES THE BREAST. If your nipple areola and down near your crease, at the crease, or below the crease, you will need some kind of a lift to get the best final look. The farther down they are, the higher they need to move and the more lifting and scars they need to get the best result.

In my opinion, a submuscular implant of proper dimension and profile to suit your frame and desire for either a natural upper pole or a fuller than natural upper pole gives you the best volume enhancement for your body. The implant is like the framing of a house. The finish work is then done with the lift if you need one to elevate the nipple, reshape the breast and tighten the skin envelope.

Subglandular breast implants can sometimes compensate for breast sagging

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I am glad you consulted 2 surgeons-call them and express your concerns and ask to see pictures of their results with a breast like yours.

Many surgeons prefer submuscular breast implantation because there is less chance of capsular contraction and more tissue will cover the implant. The latter is important for women who have very little breast tissue-which sounds unlike your situation.

A mature, slightly sagging breast often looks better with an implant placed beneath the breast tissue and not the muscle. The implant fills the empty breast envelope and can lift the breast and push the nipple areola complex upward.

I almost always place implants under the muscle in small breasted women and women who have not had children and breast atrophy.

However, in women who have had children, have an atrophic "deflated " breast, and have some sag, I usually place the implant beneath the breast to get a little lift.

Putting the implant beneath the muscle always leaves the implant a little higher and this can accentuate the sag rather than correcting it.

Yes, things can get confusing!

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There is no best or right way to do an augmentation. You just have to prioritize the things you want or don't want. In general, since sagging is usually caused by laxity or excess of skin, filling it out is often more effective with implants over the muscle because the implants lies closer to the skin. It is also where the breast tissue normally lies (i.e. over the muscle). Depending on the size and model however, since the implant is closer to the skin, you might start to "see" the implant more than if it is under the muscle.

Round implants can look more round, rippling can be more obvious, fullness can be exaggerated. Implants under the muscle are generally considered "safer" because they stay softer longer, you get better mammograms, and the breast tissue is protected in part by the intervening muscle even though that is not where breast tissue normally lives.

While some sagging can be corrected, since the implant and the breast tissue are disjointed from each other because of the intervening muscle, sagging skin can often "fall off" the implant with the breast gland producing a double bubble or Snoopy's snout type of deformity. You generally require a larger implant under the muscle because the implants are "hidden" more from the skin. Some perception of sagging can be aided by placing the implant lower on the chest so that the nipple lies higher relative to the equator of the implant but there is limit as to how low you can place the implant.

Only a careful analysis of your anatomy and what your desires are can point you in the right direction. It is possible that each surgeon is "right" in his own analysis. You might want to see a third for a "tie breaker" opinion but be mindful that the more surgeons you go to, the more confused you could get. At some point, you'll have to a "leap of faith" that the surgeon you trust will achieve what you want.

Robin T.W. Yuan, MD
Beverly Hills Plastic Surgeon

Placing the implant above the muscle may avoid a breast lift in a modestly droopy (ptotic) breast.

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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.

Too much confusion with breast implant placement

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Hi there,

There are a few things to know and understand that I think will really help you be more comfortable, however you proceed. First, I think that you should choose a surgeon based on their training and expertise with the procedure in question, and your impression of their compatibility with you. It is a relationship after all, and you need to like them and get along well. Any individual surgeon will know what works well for them, and the operation one prefers for dealing with your situation and achieving your goals may not be the same approach another excellent surgeon would take. They may very well both be able to get you where you want to be, but may prefer different routes. You will need to decide which route is most comfortable for you.

Having said all of that, I personally prefer to place implants under the chest muscle in most of my patients (the only exception is body builders), because this placement will lower the risk of multiple problems, maintain the blood supply to the breast tissue better (which is especially important if you need a breast lift), lower the risk of losing feeling in the nipples, and make mammograms better and easier. There is no reason to believe that placing them under the muscle will compromise your ability to achieve any particular shape or size, and I have patients of all shapes and sizes (with breasts to match) with implants under the muscle. It does hurt a bit more for the first week, but I think the long term benefit is worth it in almost all cases. I hope that helps.

Breast Implant Placement Pros and cons

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There are pros and cons for each approach:

1. Below the muscle (or dual plane):

Better implant visualization on mammogram

Better protection for the implant

Better used in very thin patients with little breast tissue

Better used in saline impants due to future rippling

2. Above the muscle:

Better projection

More natural result specialy with a gel implant

Hisham Seify, MD, PhD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 19 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.