Should I get over or under the muscle with 345 cc mods to correct mild drooping? (Photo)

This is a frequent question - and one of the 4 questions my patients must answer.  1) Type of implant2) Location of incision3) Above or Below the muscle4) Size of implantsWhether to go above or below the muscle depends on the amount of breast tissue you have to hide the implant, the type of implant you choose, and types of activities you plan to do.  If you lie in bed and pull the sheet over your toes - you see your toes.  Pull up the comforter - you see bulges.  If you have enough breast tissue to be a comforter - ok to go above muscle.  Silicone implants have less ripples than Saline implants - that is a factor.Capsular contractures - 6% under muscle , 7% aboveIf you have a strong family history of Breast cancer, under may be preferable in expectation of potential needle biopsies.  Ask your Plastic Surgeon - based on his understanding of what you want to achieve.

Breast implants are usually placed under the pectoralis muscle to decrease descent of the implant, capsular contracture, and palpability of the implant. Most patients will be better candidates for implant placement underneath the pectoralis muscle. This provides an added layer of tissue over the implant and helps to conceal the shape and outline of the implant. I recommend discussing these options with your board certified plastic surgeon, who can individualize your treatment plan.

Thanks for your inquiry and excellent pictures.  You can get your wish breast look by placing the implants under the muscle.  Please discuss your desire to be under the muscle with your surgeon and good luck.  

To the question of going above or below the muscle with a breast implant, there is no single correct answer. Typically, I prefer smooth regular gel implants below the muscle (biplanar position), and cohesive gel implants when I go above the muscle. My concern is the presence of ripples in the superior pole of the breast if you use a regular gel or saline implant below thin and loose tissue. There are also questions of capsular contracture risk with subglandular placement. I think that your goal breasts are attainable with either approach. Keep talking to your surgeon, they are likely your best source of information.

Your photos are not the best, but they suggest that you may have some degree of glandular ptosis (drooping or pseudoptosis) which is a condition where the breast gland is sagging, but the nipple is a separate issue. In my (humble?) opinion, I do not believe there is an indication in a primary (first time) breast augmentation to place an implant above the muscle. While this may make some of my colleagues cringe a bit, it is an opinion and nothing more. Using a technique called a "dual plane" placement, first described by Dr. John Tebbetts, a breast pocket is created that is below the muscle, but has some of the benefits of a pocket above the muscle, including better ability to deal with glandular ptosis. I would strongly suggest that you get an opinion from a surgeon familiar with the technique, as I believe, as best I can tell from your photos, that you are a very good candidate for this.

The advantages of placing the implant ABOVE the muscle are that this mimics the natural breast, since there is no breast tissue below the muscle anatomically. There are four reasons implants are placed under the muscle:1. There is the theoretical advantage of reducing the risk of capsular contracture (hardening, distortion, and possibly pain).2. You eliminate the possibility of "animation deformity", the movement or "twitching" of the breast when you activate your pectoral muscle.3. The muscle does provide some coverage or camouflage of the round implant thus creating more of a tear drop appearance to your implant as it sits beneath your breast. 4. Mammograms are a bit easier to interpret when the implant is under the muscle. As several of my colleagues have suggested, your own breast tissue needs to be adequate enough to cover your implant if it is place above the muscle, and a more natural appearance is likely to be obtained if a lower profile implant is selected when placed above the muscle. The higher profile implants have a risk of looking artificially round and proud, not what you think of as a "natural" appearance.Discuss all of this with your plastic surgeon. If you are not confident, do not be reluctant to seek a second opinion. Make sure that your sense of aesthetics aligns with that of your plastic surgeon's based on this or her before and after gallery of photos. The implant you have theoretically selected is relatively conservative in size, and that is consistent with a more natural appearance, but any opinion on REALSELF regarding your specific treatment plan or implant size should not be considered as valid as one that is arrived at after an evaluation in person. Based on your photos, however, if the decision is made to place the implant below the muscle, it will need to most likely be "dual plane", meaning that it is kind of a compromise between the two techniques, and one that make the implant position more "suglandular" that a straightforward "sub pectoral". Best of luck to you. 

Hello and thank you for your question. There are several advantages
and disadvantages to over vs under the muscle.  Under the muscle has the
advantage of lower capsular contracture rates, less risk of rippling, and
better visualization with future mammograms.  Most patients say that under
the muscle also has a more natural look and feel.  The size, shape,
and profile of the implant is based on your desired breast
size/shape, your chest wall measurements, and soft tissue quality. 
This decision should be based on a detailed discussion with
equal input from both you and your surgeon.  This entire surgery can be performed with a
small incision technique.  Make sure you specifically look at before
and after pictures of real patients who have had this surgery performed by your
surgeon and evaluate their results.  
Best wishes and good luck.
Richard G. Reish, M.D.
Harvard-trained plastic surgeon

I appreciate your question.

The best way to determine implant size is based on chest wall measurements that fit your body.  Once we determine that we can choose the profile based on what you want or need to achieve.  

Implants under the muscle, there is less risk of capsular contracture.  Anatomic implants tend to give a more natural shape with more nipple projection.

The best way to assess and give true advice would be an in-person exam.  Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.

Best of luck!

Dr. Schwartz

Board Certified Plastic Surgeon

#RealSelf100Surgeon

#RealSelfCORESurgeon

Thank you for your question. Based on the picture you do not need lift. Implant can be placed either plane. I prefer under the muscle to our patients as it gives smooth appearance at the top part.

 I think that you could do fine with either above or below the muscle. The rationale for placing the implant underneath the gland is that it gives a slightly fuller appearance and is thought to lift the nipple more.  It is important that there is adequate  breast gland to cover and camouflage the implant if it's going to be placed underneath the gland. Many surgeons place implants in the sub glandular position and have great results. More recently, more surgeons have been shifting towards  partial sub muscular placement because of the lower rates of capsular contracture. Discuss your concerns with your surgeon.