550cc Implants Should I Go Above or Below the Muscle? (photo)

Question

I'm 42 years old 5' 11" and 245lbs my breast augmentation is two weeks. what would give me te best look.

Lewis Albert Andres, MD · Answer

Hello! Thank you for your question!  Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts.  Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years.  In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance.  Your breast width is the most important measurement.  Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant.  This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape.  Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width.  Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later. Very slightly less tissue may be visualized with subglandular implants, but not very significant.Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle).  Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each.  In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome.  A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles.  Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions.  As you see, there are a few factors to decide upon for incision, placement, and implant type/size.    Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits.    With the little breast tissue you have as well as the large implant, subpectoral may be a better option.  Hope that this helps! Best wishes for a wonderful result!

Tom J. Pousti, MD · Answer

Thank you for the question.
	There are pros and cons to the placement of breast implants and the “sub muscular” position versus the "sub glandular position”.    I will try to outline some of the differences here;  you may find the attached link helpful as well.
	I think it is in the best interests of most patients seeking breast augmentation surgery to have implants placed in the “dual plane” or 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 breast implants in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position.

	On the other hand,  sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants  seen with flexion of the  pectoralis major muscle)  they can be seen with breast implants placed in these sub muscular position.  Also, the immediate recovery period may be  more comfortable  after sub glandular breast augmentation as compared to sub muscular breast augmentation surgery.

	Best wishes with your upcoming surgery.

Kevin Tehrani, MD, FACS · Answer

Thank you for your pix. You are a good candidate for breast augmentation. Two considerations:

1.  Placing the implants under the muscle in you is very important to provide a more natural look and coverage of the implant.

2.  Placing the implant through your areola would be difficult, hence your fold under the breast needs to be planned very carefully to place the scar in your new to be fold.

Please see a board certified plastic surgeon with expertise in this area.

Curtis Wong, MD · Answer

continues to be debated fiercely by proponents in each camp.  My own experience suggests under the muscle may provide a longer, better results and avoid the 'rock in a sock' look as you get older.  I prefer the dual plane technique for the following reasons.

	1) more fullness in the upper pole with a more natural slope from chest wall to breast

	2) avoid visible rippling  in the upper pole since its covered by muscle

	3) better mammograms under the muscle

	4) and most importantly, less risk for contractures under the muscle.

	The only 'con' about going under the muscle is that your breast will move/contract when you contract your chest muscles and I advise my patients they are not longer to participate in strengthening activities for their chest muscles.  I was once associated with another doctor that advocated going above the muscle.  The community consensus favors under the muscle.

Remus Repta, MD · Answer

Hello,

	Thank you for the photos.  If you are considering having an implant placed on top of the muscle I would encourage you strongly to only consider silicone.  For that size implant even if you place the implant under the muscle an appreciable percentage of the implant will be below the lower border of the muscle and therefore not under the muscle (dual plane).  Make sure your plastic surgeon selects the proper implant width and projection based on your body and goals.  After that, it will really not make much of a difference between under or over the muscle.

	All the best,

	Dr Remus Repta

550cc Implants Should I Go Above or Below the Muscle? (photo)

Answers (10)

Answer: Augmentation over or under the muscle

Answer: Augmentation over or under the muscle

Answer: Silicone implants and the width/projection of the implant will be most important decision

Answer: Silicone implants and the width/projection of the implant will be most important decision

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Everything you need to know about Breast Implants

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550cc Implants Should I Go Above or Below the Muscle? (photo)

Answers (10)

Answer: Augmentation over or under the muscle

Answer: Augmentation over or under the muscle

Answer: Silicone implants and the width/projection of the implant will be most important decision

Answer: Silicone implants and the width/projection of the implant will be most important decision

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Recommended reading

Everything you need to know about Breast Implants

Our mission is to create a world where every investment in modern beauty is Worth It.