Breast Augmentation Decision Confusion about Subglandular or Submuscular Placement.

Ive been researching subglandular and submuscular for weeks now. im not sure where the best placement for my body is! Ive had a little weight loss and my breasts have sagged slightly this past year. Ive been to 2 consultations and both Drs said different things. Also, not sure what size to get either but was recommended 275-325cc silicone. i want to fill out where my breasts look flat and empty above and on the sides of my chest while achieving perkiness and the most natural looking and feeling

Doctor Answers 32

4 options for breast implant placement, not just under or over muscle

Though we have traditionally considered only 2 options, there are actually 4 in use today: subpectoral or under the muscle (typically "dual-plane"), subglandular (in front of the muscle), subfascial, or split subpectoral. The first part of the decision is coverage; a thin patient will usually do better with under muscle placement. However, with the implant under the muscle there is the potential for distortion of the breast with muscle flexion, called animation deformity. This occurs to some degree with the majority of patients who have implants under with the dual-plane technique. The subfascial technique is above the muscle but behind a layer called fascia (pronounced like "fashion"), which is thin but may add some support. Finally, the split muscle technique allows for muscle coverage over the upper part of the breast while minimizing the risk of animation deformity with athletic activity.

Seattle Plastic Surgeon
4.9 out of 5 stars 52 reviews

THere are advantages to both the submuscular and subglandular placement of the implants in

breast augmentation, and the decision is too complicateed to make on line without a consultation and a discussion with the patient to determine her goals and expectations.  The submuscular placement helps hide any rippling and smooths out the "feel" of the implants.  If your preference is a saline implant, and particularly if you are thin without a great deal of breast tissue to cover the implant, this becomes an extremely important consideration.  Mammograms are also more revealing if the implant is in the submuscular position.  On the other hand, if you have a small amount of ptosis (drooping of the breasts) and nild skin laxity, subglandular placement will take up the laxity much more efficiently, and will provide a small amount of lift.  Here choosing a silicone implant would be more important.  In summary, this decision is the result of a process of discussion and education, and to make the best possible choice for your particular situation a consultation and frank discussion are critical.

Michael H. Rosenberg, MD
Mount Kisco Plastic Surgeon
5.0 out of 5 stars 2 reviews

Sub-glandular vs. sub-muscular breast implant placement

As in researching the issue, it's clear that you won't get a solid consensus on this issue with plastic surgeons. 

I agree with Drs. Law, Rand, and Pousti among others here. The reason to do breast augmentation with the implant under the pectoralis muscle for the central, upper, medial part of the breast is because of experience with thousands of patients over many years. The results are better and more controlled (assuming the surgeon knows how to size the implant properly and to get the implant under the pectoralis muscle and dual-plane release the inferior/lateral border) both short term and long term. In my opinion, any plastic surgeon who uses a sub-glandular placement of an implant doesn't know how to get the implant under the muscle properly, doesn't follow patients long term, or doesn't want to use extensive experience of others and will do whatever the patient says they want. 

The one trade-off of sub-pectoral implant placement is the animation-distortion of the breast by maximal flexing of the pectoralis muscle. This has been minimized by proper dual-plane release of the pectoralis muscle out of the lower pole of the breast. Not all plastic surgeons are familiar with the issues of releasing the pectoralis muscle properly.

Sizing the implant is another issue but proper sizing and its effects is based on sub-pectoral placement. The same volume implant will make a bigger looking breast if the implant is above the muscle as compared to an implant blended in by the muscle for the central/upper/medial part of breast. This is why sub-pectoral implants look more natural and although someone with thick skin, lots of fat, or lots of breast tissue can "get away" with a sub-glandular silicone gel-filled implant in the short run, most such implants will become visible to various degrees as the patient ages. 

Scott L. Replogle, MD
Boulder Plastic Surgeon
4.0 out of 5 stars 1 review

Subglandular vs Submuscular

The term subpectoral and submuscular are often used interchangeably and describe placement of the breast implant beneath the pectoralis major muscle, which lies under the breast tissue. This position is the most commonly used and allows the superior and medial portion of the implant to be covered by breast tissue and muscle. Subpectoral placement is best for thin patients with little (less than 2cm) superior breast or subcutaneous tissue. This position helps decrease the chances that the implant will be visible through the skin postoperatively and may decrease longer-term complications like capsular contraction. However, some patients may notice implant movement with contraction of the muscle.

A subglandular implant is placed below the breast tissue but above the pectoralis major muscle. This position is best for patients with thicker upper chest skin, those with minimal ptosis (i.e. drooping of the breasts), or women with previously placed subpectoral implants requiring certain revision operations.

Jaime Perez, MD
Tampa Plastic Surgeon
4.8 out of 5 stars 75 reviews

Breast Implant Position

My preference when possible is to place the implants underneath the chest wall muscle as I  feel long term there are less problems. Without seeing photos and examining you , I would hesitate to make recommendation.

Richard Linderman, MD
Indianapolis Plastic Surgeon
4.9 out of 5 stars 9 reviews

Submuscular Vs Subglandular Implant Placement

Submuscular implants as the name implies are placed at least partially below the pectoralis muscle whereas subglandular implants are placed on top of the muscle.  I place 95+% of my breast implants below the muscle which I feel usually gives a softer and more natural result.  The downside is a bit more discomfort for the first few post-op days and the need for a strap on the upper breasts to encourage the implants to descend into a favorable position.  Perhaps you should seek a third opinion since you have had 2 divergent opinions already.  You might also benefit from a lift if your sagging is significant.

John Whitt, MD (retired)
Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Above or Below: Never Ending Debate

Thanks for the good pictures.  The big debate about underneath or above the muscle revolves around coverage. This is judgement made at your exam.  if your tissue is thin above the breast then placement of the implant beneath the muscle is warranted. if there is ample tissue in this area then placing the implant above the muscle is reasonable.  As an educated guess I would place your implant beneath the muscle.


Breast Implants Selecting the apropriate position

This may be a somewhat controversial statement, but in my opinion there currently is really only one acceptable position for breast implants in an elective cosmetic surgery patient: behind the pectoralis major muscle (sub-pectoral augmentation). There are a number of very compelling reasons to place implants behind the pec major, and the most compelling one of all is the fact that radiologists report that the mammographic imaging of breasts for the purpose of breast cancer screening tends to be more easily accomplished when breast implants are sub-pectoral (compared to pre-pectoral, also referred to as the 'sub-mammary' position). An American woman's current lifetime risk of breast cancer is approximately 1 in 8 to 1 in 9, so the issue of breast cancer screening must be taken very seriously. Mammography is by no means a perfect screening study, but it is the standard of care at this point in time. The most sensitive and specific test for breast cancer is a contrast-enhanced MRI scan, and breast implants do not impair breast tissue visualization by MRI.
The next very compelling reason to select sub-pectoral placement is a cosmetic one. Implants placed on top of the pec major tend to stand out in the upper pole of the breast, creating a rounded, convex and distinctly unnatural-appearing breast profile. With implants in a sub-pectoral position, the upper pole of the implant is flattened somewhat by the muscle, helping to create a smooth transition from the area in the upper chest where the breast begins, and a gradual slope towards the nipple that is not excessively rounded or convex. In some patients with a fuller breast volume preoperatively one may get an acceptable appearance with pre-pectoral placement - initially. The problem is that as breasts age, the fatty tissue atrophies and breast tissue thins out, and the area where this is most obvious is in the upper pole and cleavage area. So a pre-pectoral implant that was initially well-concealed may, after a few years, become painfully obvious (including visible implant folds and ripples) in the upper pole.
'Under the muscle' and 'sub-pectoral' are actually somewhat misleading terms, as in most cases the implant is only partially subpectoral. The anatomy of the pectoralis major muscle is such that it is actually just the upper/medial half of the implant that is covered by the muscle, while the lower/lateral half of the implant is submammary. The pectoralis major thus provides an additional layer of tissue to conceal the implant in the most cosmetically significant area of the breast: the cleavage area. This is why saline implants are often easy to feel laterally, as they are covered by breast tissue only in lateral aspect of the breast, and in slender patients who have small breasts preoperatively the implant is often immediately under the skin in this area.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 118 reviews

Sub muscular implants

Sub glandular implants do not "lift" the breast, can gave problems with tissue thinning and changes and have a higher rate of contracture. I see very little reason to go in the sub glandular position and almost entirely use the sub muscular, dual plane position. You will do well with this procedure.

David Nicholas Csikai, MD
Jacksonville Plastic Surgeon
4.8 out of 5 stars 65 reviews

Submuscular placement has more benefits and less risk of sagging.

I have found that the submuscular location results in: 1)more tissue covering the implant for a more natural look 2) improved mammograms when compared to the subglandular implants and 3) decreased rate of capsular contracture. 

Plus, subglandular implants often sag over time. 

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 81 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.