Do you think I have enough breast tissue to get my implants over the muscle? (photo)

I am 20 years old, 32b (not fully filled) and would have to get saline unless my surgeon agreed to give me silicon "off label" which I'm not sure I would be willing to do. I've read about the much faster recovery times and better cleavage results by placing the implants over the muscle, and since I feel (maybe I'm wrong) that my breasts are wide-set, I would love to have the option of getting more cleavage. My consultation isn't for a few weeks & I just wanted to get an idea.

Doctor Answers 14

Subglandular vs. Submuscular

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I understand your desire to minimize your postoperative discomfort and to maximize your cleavage.  Fortunately, recovering from a submuscular augmentation does not have to be difficult if the procedure is done with an as gentle a technique as possible.  The benefits of muscle coverage are significant and, I believe, well worth the minimal increase in discomfort that you may experience.  Placing saline implants above the muscle in a thin patient can be a problem with respect to rippling and feel of the breast as well as the appearance of the breast.  Also, if an attempt is made to make the cleavage very narrow above the muscle you may only have the very thin skin near your breast bone to cover the implants and rippling can be very noticeable.  Try to think long term about your decisions as they will impact your appearance for the rest of your life. 

Simultaneous lift

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The goal of breast surgery is to create beautiful breasts.Since your breasts are too far apart and low, I recommend a simultaneous lift.Women refuse lifts because of the ugly vertical scars of the traditional technique.That is why a new technique was developed called The Mini Ultimate Breast LiftTM.Using only a circumareola incision is it possible to reshape your breast tissue creating upper pole fullness, elevate them higher on the chest wall and more medial to increase your cleavage.Aligning the areola and breast tissue over the bony prominence of the chest wall maximizes anterior projection without the use of implants.This will solve your cleavage problem better than implant placement or type.

Best Wishes,

Gary Horndeski, M.D.

Breast implants over muscle

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Thank you for your question about breast implants going over the muscle.

Your photo suggests you definitely have enough tissue for placement of implants in this position. Saline implants are easier to feel even when they have good tissue cover. But I know and have many patients who have these implants over the muscle and are very pleased. The implant size should not be excessively large - big implants will tend to stretch the skin.

You are too young by law for gel implants. Also they are more expensive. Best wishes.

Which pocket is best for your implants?

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You are correct in that with an age below 22, the FDA guidelines mean that you would be using gel implants "off label".  That said, I recommend placement of either type of implant below the muscle for a more natural appearing result that will be longer lasting and have a lower risk of rippling and problematic scarring.

As far as your cleavage is concerned, you will need to have an extensive discussion with your surgeon.  In your case, your nipples are quite lateral and placement of your implant centrally in order to create cleavage is going to give you a result in which your nipples are pointing to the side rather than forward.  While there are maneuvers to help with this and move your nipples as well, this surgery is more extensive than simple breast augmentation and something that should be discussed with a board certified plastic surgeon.

You are the perfect example of how a breast implant operation needs to be tailored to the specific needs of the individual patient.  Best wishes for your surgery!

Good candidate for silicone gel implants on top of the muscle.

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In my opinion you are a good candidate for silicone gel implants. I would personally recommend that they be placed in a sub glandular position. I'm not sure what you mean by "off label" implants.

Better choice may be a gel implant under the muscle

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You are correct that the use of a gel implant in a woman under 22 is off label.  Since you have thin skin and not much breast tissue to cover the implant a gel implant may give you a better result.  I would not consider a saline filled implant above the muscle since the implant will be more palpable and there is a higher risk of a capsular contracture.  


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No one has ever been able to tell me why the FDA arbitrarily chose less than 22y/o as off-label for silicone. The recovery between sub-pectoral and submammary at your age is negligible.

Do you think I have enough breast tissue to get my implants over the muscle?

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That question cannot be answered without an examination. There is no scientific reason for withholding silicone implants because of a certain age, but at preseent they are off-label at your age. Saline over the muscle is a high chance of an unsatisfactory result.

Over or Under the Muscle?

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I would most definitely place your implants under or behind the pectoral muscle. I strongly feel that there are many more advantages to placing the implants behind the muscle, including to but not limited to, better breast cancer detection in the future by mammogram ( as opposed to in front of the muscle or subglandular). In addition, I feel that the eventual result is a much more natural looking breast. Although implant companies have a rule that patients below the age of 22 must use saline implants, there are  some exceptions that justify the use of silicone gels in patients below the age of 22. One of these is the potential for rippling or wrinkling whereby the saline implant has folds and pleats which become palpable and visible under the skin. If you have them done beneath the gland instead of the muscle, it is my humble opinion that you will experience a great deal of wrinkling. In,addition there is no question that silicone gel implants feel more natural than saline.

Therefore, I would suggest the use of silicone gel implants moderate-plus profile 350ccin a subpectoral location through either an inframammary or periareolar approach. Good luck

Above the Muscle

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Thank you for your pictures.  I would not place you implants over the muscle.  An exam would give you the best answer because you can feel the tissue thickness.  You look like your tissues are thin above the breasts.  You cleavage can not get any closure because your natural breasts are not close.

Earl Stephenson, Jr, MD, DDS,FACS

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.