Are 405 or 445 cc implants the better choice for me? Will going over the muscle accelerate sagging? (photos)

Question

Hi I'm scheduled for ba in March and I'm worried about my choice of implant. At my last appointment I decided on 445cc moderate silicone implant over the muscle. My surgeon said that with my bwd I wouldn't be able to go smaller than 405cc but when I tried on the sizer I was afraid that it wouldn't fill out my existing breasts. Should I go with 405cc or 445cc? And will going over the muscle with this size make them sag faster?

William Andrade, MD · Answer

Thank you for your question.  It sounds like you are down to choosing two implants that are similar in size, and your surgeon will be the best source of advice whether to go a little bigger or smaller.   In addition to your goals for the final size, they need to consider anatomical factors like your breast dimensions, skin tone, and tissue thickness, which are all measured in person.  Photographs can't provide the same information.  Breast sagging can occur whether implants are inserted in front or behind the muscle but the outcome looks different ("snoopy nose" vs "ball in sock" appearance).

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation (“overs”):

•	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 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.

•	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 (“unders”):

•	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.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.

•	Subpectoral implants have a lower rate of capsular contracture.

•	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. 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.

Camille Cash, MD · Answer

The difference in the size of the implants you are considering is not significant and one may simply fit the space better than the other.  I use sizers during surgery to help my patients achieve their desired look. As for sagging, the heavier the implant, the more it can contribute to sagging.  Having the implant placed under the muscle can help by supporting the implant somewhat, taking some of the weight burden off of the skin envelope.

Daniel Barrett, MD · Answer

Dear Tough332388,
breast implant type and sizing selection is a complicated process and requires a detailed consultation that includes a discussion of your goals, a detailed examination, and a lengthy discussion. But the decision will always start and end with the patient. When it comes to sizing, we have all of our patients find 3 photos of their desired breast size. We ask for naked breast photos because clothing can obscure the true size (push up bras). Next, we consult with patients and go over the photos and take detailed breast measurements during a physical exam. Next, we using a sizing algorithm to determine a range of implants that will work based on the exam and the measurements.Lastly, during the operation, we use silicone sizers in the operating room to see how the size actually looks in the breast. We sit the patient up in the operating room, while asleep of course, and compare the sizer result with their desired look photos. If it is too small, we start the process over with a slightly larger implant. We don't stop until we get the perfect match.Of all of my breast augmentation patients, every one of them has been happy with their size due to this detailed and meticulous process. You don't want to invest time and money into a result that is either too big or too small.You should discuss your concerns with a board-certified plastic surgeon and make sure that your surgeon understands your goals.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Luis A. Mejia, MD · Answer

Dear Tough332388, thanks for sharing your pictures and photos, as bigger implants more chances of sagging, implants sizes selection are maybe the difficult step in this process, I do suggest to take a sit with your surgeon and talk about it, discuss your desires and listen his or her recommendation about, in order to meet your expectations. However it is impossible to pick or recommend style, shape or sizes without an in person consultation, that provide the chance to get the measurement of key breast parameters. Make sure you go on consultation with a board-certified plastic surgeon. Hope this helps and best of lucks. Dr. Luis Mejia

Are 405 or 445 cc implants the better choice for me? Will going over the muscle accelerate sagging? (photos)

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Answer: Implant size

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Everything you need to know about Breast Implants

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Are 405 or 445 cc implants the better choice for me? Will going over the muscle accelerate sagging? (photos)

Answers (10)

Answer: Implant size

Answer: Implant size

Answer: My Recomendation

Answer: My Recomendation

Browse related questions

Recommended reading

Everything you need to know about Breast Implants

Our mission is to create a world where every investment in modern beauty is Worth It.