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

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).

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.

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

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

Your breasts are low on the chest wall. The technique I recommend is a circumareola approach and retro-pectoral implants. I do not recommend 445 cc implants as they weigh almost 1 lb each. When placed in front of the muscle, the only thing holding them up is the skin envelope. Also, when placed in front of the muscle you are cutting the supporting ligaments of the breasts and the breasts will sag even sooner.

Best Wishes,

Gary Horndeski, M.D.

You could go with either. The bwd and sizers do nothing but confuse you. I suggest you look at some results online where the size is listed to help make your decision

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.

There is not a big different in the two sizes, so go with the larger. However, you might want to consider going under the muscle. On top of the muscle, there is much less support for the additional weight and you will sag more quickly.

Dear Tough,
One hundred different plastic surgeons might give you 100 different opinions. You have chosen a surgeon for your breast augmentation and it is imperative that you trust his or her plan of action. The difference between a 405 and 445cc implant is not that significant as to worrying about one sagging faster than the other. In general, breast implants placed above the muscle tend to age (sag) more than under the muscle. Good luck!

Each plastic surgeon will have their own way of guiding patients through the implant selection process.
Different plastic surgeons do this very differently.
There are generally three variables that determine the outcome of a breast documentation.
The first is the patient candidacy for the procedure.
Not everybody is an ideal candidate for breast augmentation.
The second is a choice of implants in regards to size type and shape.
The third variable is the surgeons ability to technically place the implant and the correct anatomic location.
It seems to me that most plastic surgeons who have extensive breast augmentation practices typically prefer placing implants under the pectoralis muscle.
Placing the implant above the muscle is technically much easier, but under the muscle has a lot of advantages.It’s not really appropriate for us to tell you what implants to use.
This is something you should have your provider help you with.
Personally, I use before and after pictures to get an understanding of what my patient is trying to achieve.
During surgery I use temporary sizers to determine what implant will create the size or final outcome. The patient had chosen.
I don’t have a full selection of implants at my disposal, and choose to implant based on using a sizer during the operation.
I don’t find that placing implants in the bra is an accurate way of judging implant choice.
Like I said, each provider will have their own way of doing this.
Some providers do it better than others.
I generally recommend patients consider having multiple consultations before selecting a provider.
Best,
Mats Hagstrom, MD