Is Subglandular Breast Implant Placement Right for Me?

I'm a mother of 2 who breastfed so I do have some ptosis. My current size is a 36B but am looking to only go maybe to a large C at most. I have been to a plastic surgeon for a consultation and he suggested placing the breast implants subglandular. I was wondering if his opinion would change since I'm still losing weight. Also, I'm leaning towards saline implants instead of silicone now. How many consultations should I get before proceeding with the procedure?

Doctor Answers 11

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Subglandular placement is acceptable if you have at least 2cm of tissue pinch in the upper pole.

That being said, the most important factor that keeps the breast looking natural over hte long term is tissue coverage, and that is greater when it is behind the muscle.

But the notion of thinking that there are just two choices - in front and behind the muscle - is obsolete thinking. Today we do "dual-plane" augmentation, in which there is muscle over the implant towards the center and upper part of the implant, where coverage is most needed, yet there is no muscle over the lower pole of the breast, where direct appostion of the implant against the lax breast envelope helps fill out a droopy envelope.

In fact, there is little if any advantage of subglandular over dual plane, other than some possible minor animation deformity when strongly contracting the muscle.

The one thing you mentioned that I strongly disagree with is using saline implants in the subglandular position in a ptotic breast. Many surgeons have observed that saline implants tend to cause greater stretch in the droopy breast, possibly as a result of their greater weight and of a "water-hammer" effecte of the sloshing of hte contents. Furtermore, silicone implants lesser tendency to ripple and fold give them the advantage in the reduced coverage environment in front of the muscle.

Finally, you must be sure that you don't need a lift. One of the most frequent reasons women have unsatisfactory results after augmentation is the post lactation/weight loss atrophy/ptosis patient who gets a large subglandular implant instead of getting a lift with an appropriately sized implant behind the muscle. Is your nipple to inframammary fold distance >10cm? Be sure it isn't, or you may need a lift.

Los Angeles Plastic Surgeon
4.6 out of 5 stars 49 reviews

Subglandular Breast Augmentation

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I would certainly recommend that you not do any surgery until your weight has lstabilized and your are comfortable. With a mild degree of ptosis a simple augmentation may be enough, but for moderate ptosis you may require a short scar mastopexy or more. If the skin and fat above the nipple in the upper poles of the chest are adequate then a suglandular placement with silicone implant would probably give you the most natural look and feel. You should anticipate recurrent ptosis over the years and a simple skin procedure can be done to "adjust" this.

Theodore Katz, MD, FACS
Philadelphia Plastic Surgeon

The breast implants have to go subglandular unless you also want a lift.

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Of course, you should get another opinion, but I agree with your surgeon. Even if you are going to lose weight, breast implants should be placed subglandular if you have any sagging.

In New York City, we have quite a few women with subglandular saline inplants who look and feel just fine. But in general, we would recommend smooth walled silicone implants.

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

Breast Implant Position?

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Thank you for the question.

In general, I think it is in your best interests (and that of most patients seeking breast augmentation surgery) to have implants placed in the “dual plane” sub muscular position.  This positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look  of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability  of the implants (which may increase with time, weight loss, and/or post-pregnancy changes).

The submuscular positioning  also tends to interfere with mammography less so than in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position.

The type of implant used may  determine the final outcome, especially if the patient does not have significant covering breast or adipose tissue. For example, some surgeons feel that silicone implants have a more natural look and feel than saline implants because silicone gel has a texture that is similar to breast tissue. Each patient differs in the amount of breast tissue that they have.  If a patient has enough breast tissue to cover the implant, the final result will be similar when comparing saline implants versus silicone gel implants.  If a patient has very low body fat and/or very little breast tissue, the silicone gel implants may provide a more "natural" result.
On the other hand, saline implants have some advantages over silicone implants. Silicone implant ruptures are harder to detect. When saline implants rupture, they deflate and the results are seen almost immediately. When silicone implants rupture, the breast often looks and feels the same because the silicone gel may leak into surrounding areas of the breast without a visible difference.  Patients may need an MRI to diagnose a silicone gel rupture.   Saline implants are also less expensive than the silicone gel implants.
Other differences involve how the breast implants are filled. Saline implants are filled after they’re implanted, so saline implants require a smaller incision than prefilled silicone breast implants.
On May 10, 2000, the FDA granted approval of saline-filled breast implants manufactured by Mentor Corporation and McGhan Medical. To date, all other manufacturers’ saline-filled breast implants are considered investigational.
As of 2006, the FDA has approved the use of silicone gel implants manufactured by the Mentor Corporation and Allergan (formerly McGhan) for breast augmentation surgery for patients over the age of 22.


I hope this helps.

Sublandular Breast Augmentation for mild sagging

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Subglandular breast augmentation can be a good choice for a woman such as yourself with mild ptosis (sagging) due to childbirth. If you lose additional weight, however, the ptosis may get worse. If that happens, you may need to consider doing a mastopexy, or lift, along with the implants. The disadvantage of the mastopexy is the additional scarring, however with time (a year or two), the scars do fade quite a bit. The advantage of the mastopexy is that you can have the implants placed under the muscle instead of in a subglandular position. If you do choose to have a subglandular implant, you may want to seriously consider using the new cohesive gel implants. Saline implants have a tendency to ripple over time (even when over-filled), but if the implant is positioned under the muscle the rippling is less evident. Either way, it's a good idea to finish losing most of your post-baby weight and to have at least one other consultation before making any final decisions.

Pamela B. Rosen, MD
Coral Springs Plastic Surgeon

Weight Loss and Placement of Implants

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Thank you for your question.  I think it is important to begin by saying that the best advice can only be given following a physical exam, thorough discussion of your goals, and in-person consultation.  With regards to the affects of weight loss, a significant amount of weight loss can definitely affect both the size and shape of a patients breasts.  Additionally, weight loss can affect the tone and elastic nature of the skin.  In some patients significant weight loss can be upwards of 30lbs and in others even a loss of 5-10lbs can affect the cosmetic appearance of the patients breasts.  For this reason, I generally recommend that patients wait until they have reached, are close to their goal weight, or until their weight loss has stabilized prior to undergoing any cosmetic surgery procedure (breasts included).  

A common misconception is that breast implants are used to correct breast ptosis or droop.  Another common misconception and to this end, is that the position of the implants relative to the chest (pectoralis) muscle can correct breast droop.  Breast implants are utilized for the purpose of providing patients more breast volume or to counteract the loss of upper pole firmness and fullness that can arise following pregnancies, weight loss and/or breast feeding.  If a patients breast sag, they are most likely a candidate for a breast lift as well as an augmentation to provide for the best result.

I do not believe that there is a certain number of consultations that a patient should go on before choosing a plastic surgeon and proceeding with a procedure.  Instead, I believe that it is most important that a patient finds a board-certified plastic surgeon who is well-experienced in the procedure of interest and whom they feel comfortable with.  Each surgeon has their own specific philosophy on the placement of implants (subpectoral vs. subglandular) and surgical technique, and understanding the pros and cons of the proposed procedure as well as any alternative options is of the utmost importance before making any decisions.    I hope you find this helpful and best of luck!

Weight loss can make breasts saggy

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When you lose a lot of weight, it can affect the shape and size of your breasts. After you've lost the weight, you may find that your breasts are saggier. This would warrant a breast lift. That's why I think you should hold off on having consultations until you've reached your ideal weight. Then, your surgeon can give you better advice.

Ronald Levine, MD
Toronto Plastic Surgeon
4.6 out of 5 stars 25 reviews

Seek consultation until comfortable and all questions answered.

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Implant placement relative to the pectoralis major muscle continues to be a source of controversy.Although the majority of plastic surgeons prefer submuscular placement, there’s still a large group of plastic surgeons who feel strongly about subglandular placement.Each group can make convincing arguments regarding their position of choice.It’s safe to say both approaches have advantages and disadvantages.
In the context of these discussions, we feel that every patient needs to be considered individually.Each patient has unique anatomic findings that affect the decision to place the implant under or over the muscle.The aesthetic goals of the patient are equally important and have a significant impact on the decision, as well.The vast majority of patients are striving for larger breasts with a natural look.They want balance, harmony, and proportion with the surrounding structures.
The majority of implants are placed in a submuscular position.There are several advantages to this approach.These include more soft tissue coverage, which results in fewer visible folds, creases, and ripples in the implant.This is especially important in women who have thin skin and minimal breast tissue who want saline implants.Another advantage of submuscular placement is a lower incidence of capsular contracture.This phenomena results in hardening and distortion of the breasts.Patients can also have significant pain with capsule formation.Capsular contracture can occur with the implant in either position, but the incidence is higher when the implant is placed on top of the muscle.For these reasons, submuscular placement gives a more natural look, in most cases.
Placement on top of the muscle should be considered in female bodybuilders who have large muscles which can distort the implant during contraction.In women like yourself with breast sag, implants can be placed on top of the muscle to avoid a breast lift and scarring.
Every patient should be considered individually.It’s important that you meet with a Board-certified plastic surgeon who can help you obtain your aesthetic goals.In some cases, it may be helpful to obtain multiple consultations, so you can optimize your comfort level.

Reach ideal stable weight first

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I recommend you reach your ideal stable weight before pursuing breast augmentation. This is because as you lose weight, your breasts will be affected more by ptosis, and this may be accentuated by the weight of the implants (particularly if they are in the sub glandular position). It is not the number of consultations you should have before making a decision - it's who you feel most comfortable with based on their experience, credentials, reputation and if you have good rapport with.

Breast implant placment depends

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The answer here depends upon how much ptosis you have and whether or not you want a lift. I am not crazy about saline-filled implants in the sub-glandular position as they tend to ripple especially with weight loss. Maybe you can split the difference and go for a mini lift with placement of the implants in the sub-muscular position. It is hard to tell without examining you.

John P. Di Saia, MD
Orange Plastic Surgeon

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.