Would I be a candidate for subglandular implants? Also my surgeon said I would need an internal lift from nipple (Photo)

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.

With regards to your specific question, it does not appear that you need a lift as your nipple position seems excellent. The larger the implant, the greater benefit a "behind the muscle" approach provides. As this maximizes the camouflage available to conceal the implant.

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

Hello, thank you for asking, you do not need any breast lift at the moment, just with the augmentation with implants you will look fantastic. Thank you.

Dear louiie25,
I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

The patient in the photo does not exhibit any sag to the breast. She is relatively lean. However there is no right or wrong in this question. For sure this patient is a candidate for a sub glandular implant but she is also a candidate for a sub muscular implant. There are pros and cons with each approach that should be thoroughly discussed with the patient at her consultation including differences in risks including capsular contracture with each technique. Expected results should be discussed, the accuracy of mammograms with implant positioning should be discussed, the potential of being able to feel the implant (this also depends on type of implant-gel versus saline) and the surgeon should be able to review with you not just the rationale for location but also the cons with other approaches and why the surgeon in their determination chose this particular method. I do not think there will be a significant difference based on implant size. Also remember that the chest muscle may require some fibers to be split to allow entry into this's under the muscle region and to correctly position the implant but do remember that the muscle heals. I am not sure what an internal nipple lift means or why it would be necessary to elevate the nipple in this particular individual.

I always recommend below the muscle for several reasons including better implant coverage, smoother transition in the upper pole, lower rates of infection/capsular contracture, and better long term results. I do not think that you need a lift.

The naked surgeon : breast augmentation the naked truth ibreast implant placement and incisions for breast augmentation



According to studies, more than 90% of women are satisfied with the results of a breast augmentation. This is largely because the procedure often improves a woman’s self-esteem, not to mention quality of life. We aim to custom-tailor your breast augmentation based on your preferences for perkiness, firmness, shape, and size. Our goal is to match the appropriate implant type with the right procedure so that you are completely satisfied.

Breast augmentation will enhance the shape of your breasts as well make them fuller. You may find yourself more comfortable wearing different types of clothing and may enjoy a boost in self-confidence, as is the case with many happy patients.

Usually, you can expect your breast augmentation surgery to have long-lasting effects, unless implant deflation or rupture requires surgical replacement with a new implant. Implants tend to last around 10 years before needing a replacement.

The effects of aging and gravity will eventually alter the shape and size and shape of a woman’s breasts over time. As a result, you may later elect to undergo a breast “lifting” to restore the more youthful shape, size, and firmness.th

Prospective patients should know that the final texture, shape, and appearance are not exactly the same as natural breasts. Many patients in fact prefer firmness and slightly different contours than natural breasts. However, these differences may be more noticeable in some patients than others. The intended result of the procedure is to enhance the size and shape of the breasts to achieve the body image desired by the patient.

The choices of implant placement are subpectoral (under the muscle) or submammary (under the gland, above the muscle); there are reasons to choose both of these. In the United States, subpectoral is most common, especial on the west coast. In Europe and South America most implants are placed over the muscle. Women who want a more defined implant may choose this position. Body builders with heavy pectoralis muscles may do better in this position. Very thin patients who want a more natural softer look may choose to go under the muscle.

There are also choices for incisions

The two primary methods of standa
The two primary methods of standard breast augmentation are periareolar and inframammary. A periareolar technique involves an incision along the outer edge of the areola, where it is inconspicuous in the darker skin and texture of the areola border. An inframammary incision is made in the fold where the base of the breast meets the chest wall.

Transaxillary Breast Augmentation

During a transaxillary breast augmentation, your surgeon will use an armpit incision to minimize scarring. They can then use an endoscope to precisely place the implants without having to make incisions on the breasts. The scars will be well hidden in the natural folds under your arms.

Transumbilical Breast Augmentation

Transumbilical breast augmentation, or TUBA, uses a belly button incision to insert breast implants. This technique can only be done with saline implants. Sometimes referred to as scarless breast augmentation, the benefit of TUBA is that the incision is hidden in the belly button.

Transabdominal Breast Augmentation

If you’re having breast augmentation in combination with a tummy tuck or as part of a mommy makeover, your surgeon may use the abdominoplasty incision to also place your implants, reducing overall scarring. During a tummy tuck, an incision is made along your bikini line, which can also be used to perform transabdominal breast augmentation and avoid any scars near your breasts. Like TUBA, this technique is limited to saline implants.

Natural Fat Transfer: California Breast Lift®

Implants aren’t your only option when it comes to enhancing your breasts. Fat transfer breast augmentation is a more natural alternative to implants. This procedure removes unwanted fat from other areas of your body, like the abdomen, back, or thighs. Next, your surgeon will inject this fat into the breast mound to add subtle volume and improve the shape, symmetry, and overall breast contours. Offered exclusively at Pacific Center for Plastic Surgery, our natural breast lift technique provides the slimming benefits of liposuction combined with beautiful breast enhancement.

Thank you for your pictures and questions. Let me answer them one by one.
1) SG implant - yes, you appear to have enough of your own glandular tissue present that if you wanted, you could proceed with a SG/SF implant placement. Especially if you are using the highest cohesive silicone gel implants which will limit rippling. As to whether that would "look better" I would discuss with your surgeon the differences in detail so you can understand. If you are worried about the implant stretching the skin too much, you could consider placement of dissolvable mesh or soft tissue support at the same time.
2) "Internal lift from nipple" - I am not sure this is a thing? Sounds like a fancy way of convincing you of some magic that is going to happen to the nipple from the inside, which is not a thing. If you do not make any cuts around the nipple at the time of surgery, then the nipple will not move position...period. Now you can do tricks with the implant placement to make it appear like the nipple is in a different place relative to the implant, but the nipple itself is not moving. With your arms down to your side, if your current nipple position is above the fold underneath the breast (which it appears to be in the photos) then you do not need a lift.
Hope this helps!
Dallas Buchanan, MD
VIVIFY plastic surgery
Tampa, FL

Thank you for your question. A large portion of my practice is dedicated to breast revision surgery, and I have been in practice almost 30 years. I have a whole gallery titled "Long-term changes associated with implants placed on top of the muscle". Without exception, almost every patient who has subglandular breast augmentation will end with slide down the chest and/or capsular contracture. Do not ever ever ever place implants on top of the muscle. Trust me.

I think either subglandular or submuscular would be fine. Fir you. You are borderline as far as needing a lift. I’m skeptical as to what it means to lift the nipple internally and if it will stay up

Patients with implants that are already in place but have migrated downward are candidates for modification of the scar capsule, a process of tightening it with electrocautery, placement of sutures, and sometimes reinforcing it with resorbable mesh. This has been coined an 'internal bra', and it strictly refers to the implant pocket and not the soft tissue envelope (the breast) that overlies it. Placement of implants over the muscle increases your risk of capsular contracture and reoperation; so does placement of an implant through a nipple incision. Implants over the muscle do not really improve breast shape over subpectoral when the breast is sagging, and worse, over time the sagging becomes more prominent with a 'ball in sock' appearance. Your photos are not helpful to assess breast ptosis because your arms are up or back. Any improvement to breast shape over and above placement of an implant should be met with the proper remedy: a real breast lift.