How would I benefit from over the muscle vs under outside of healing time?

Question

I'm a 32B and decided on 435CC, GB implants. My Dr suggested o-t-m, what are the benefits to this vs u-t-m?I want to be sure I make the right decision when it comes to under or over the muscle. My doctor suggested over the muscle. I'm 5'9 and 150 lbs with 32B sizing now. I do want somewhat of the "fake boob" look but not like stuck on Barbie boobs. What are the benefits to over the muscle vs under outside of healing time?

John L. Burns Jr., MD · Answer

Subglandular implants have a much higher risk of capsular contracture than submuscular pocket.  They can also appear less natural as there is not as much tissue covering the implant.  The vast majority of breast augmentations are done in the submuscular plane.  The muscle provides support, coverage, and protection against capsular contracture.

Caner Kacmaz, MD · Answer

Thank you for your question. Yes they would improve them.

Breast implants are medical devices implanted under the breast tissue or chest muscle to increase breast size (augmentation) or to replace breast tissue that has been removed because of cancer or trauma, or that has failed to develop properly because of a severe breast abnormality (reconstruction).

The FDA has approved implants for increasing breast size in women, for reconstruction after breast cancer surgery or trauma, and to correct developmental defects. Implants are also approved to correct or improve the result of a previous surgery.

The FDA has approved two types of breast implants: saline-filled (salt water solution) and silicone gel-filled. Both have a silicone outer shell and vary in size, shell thickness, shell surface texture, and shape (contour).

Kenneth Hughes, MD · Answer

Over the muscle benefits include implants are easier to place, women who lift weights find that the OTM prevents displacement of the implant when working out. Overs can give a more "fake", augmented look.
Disadvantages of OTM include ripples are more easily seen and felt, higher capsular contracture rates, bottoming out.

Nelson Castillo, MD · Answer

Thank you for sharing your question. In most cases patients benefit most from going beneath the muscle as the outcome and long-term issues are fewer.  That said, the benefits to going above the muscle would include a faster recovery with less pain, as well as a faster outcome.  Hope this helps.

Ronald J. Edelson, MD · Answer

Under the muscle hives better upper pole coverage of the implant and has lower capsular contracture rate. Above the muscle supposedly gives an impression of a lift to some people but I don’t think it does.

Daniel Barrett, MD · Answer

Dear 3i3gla45i9Ab,
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, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Kiya Movassaghi, MD · Answer

First, we should determine if you are a candidate for either over or under the muscle implant placement. What do I mean by that? If you do a pinch test of your upper pull right above your breast and the pinch test is around 2 cm of tissue or more, you usually are a good candidate for both pockets, upper and lower. If you are a candidate for both pockets, how do you decide about which one you go with? My philosophy is not to sacrifice a muscle for something that is elective, so if you can go on top of the muscle and achieve your desired result, that is my recommendation. This is especially true if you have adequate thickness to cover the muscle. On the other hand, you can go under the muscle to have a more camouflaged implant, if wanted or necessary. To place the implant under the muscle, you have to cut the muscle, whereas if you place the implant on top of the muscle, you do not have to cut the muscle. As a result, the healing time is different. If you go on top of the muscle, you heal faster because the muscle hasn’t been affected. The amount of pain you experience is also less. Those would be the main differences to consider whether you choose to go above or below the muscle in terms of healing and the amount of pain you experience immediately after the surgery.

Connie Hiers, MD, FACS · Answer

For most women, I prefer placing the implants behind the muscle to give better upper breast fullness, less fake look, less visible implant edge, and more support to the weight of the implant over time with less sagging.  In women who have a fair amount of tissue and who are not choosing large implants, I will place the implants just behind the breasts.  Long term, implants do very well behind the muscle.

Richard Guerrero Jimenez, MD · Answer

Having a breast augmentation with implants OTM give the the advantage of projecting the breast upper pole way more higher and gives you the beautiful cleavage all woman want, and having it UTM will not, but of course it will depend on the clinical evaluation of your breast and the expertise of your surgeon. I always emphasize on my patients to choose correctly the proper size based on my personal recommendation.

Robert Singer, MD · Answer

There are essentially two choices for breast implant placement: sub-glandular (under the breast tissue and in front of the chest muscle – the pectoralis muscle) or sub-muscular (under or partially under the chest muscle). The best location depends on many factors including: tissue thickness, weight, desired outcome, and individual anatomy. Each position has advantages and disadvantages:
Subglandular implant benefits:
•	A shorter recovery time.
•	Less discomfort initially. 
•	No distortion of the breast when the pectoralis muscle flexes. 
•	Mild preoperative sagging can be improved, especially if no breast lifting procedure is performed. 
•	Easier surgical procedure. 
•	Larger implants can be placed. 
 Subglandular implant disadvantages:
•	The implant may be more visible. 
•	More visible rippling, especially in patients with a small amount of natural breast tissue. 
•	Generally, saline implants do not produce a good result in front of the muscle. 
•	Higher incidence of capsular contraction. 
•	“Bottoming out” in some patients. 
•	Some radiologists have more problems reading a mammogram with an implant in front of the muscle. 
 Submuscular implant benefits:
•	Usually results in a better appearance for naturally small breasted women 
•	Less tendency for seeing ripples of the implant. 
•	A more natural feel to the breast especially in slender women who don’t have much of their own breast tissue. 
•	Less interference with mammograms, although most radiologists take additional views no matter where the implants are placed. 
•	Lower rate of capsular contraction. 
•	Less of a chance of “bottoming out” where the implant bulges at the lower aspect of the breast and the nipple and areolas tend to appear excessively elevated. 
Submuscular implant disadvantages:
•	Recovery usually takes a little longer and is more uncomfortable initially. 
•	There may be an “animation deformity”, which is a temporary distortion of the breasts when the pectoralis muscle is flexed. Body builders and weight lifters generally prefer implants in front of the muscle. 
•	It is harder to achieve cleavage in women who have widely spaced breasts. 
•	The implants often ride higher on the chest.
Actually, most patients who have breast augmentations today have breast implants placed in a combination or “dual plane” position. This approach has the same benefits and disadvantages of a total “submuscular implant”, but with a lesser tendency to ride high on the chest wall. The disadvantage as compared to a total “submuscular implant” is a higher tendency for bottoming out.
The ideal placement in any particular patient depends on their particular anatomy and understanding of the pros and cons of each approach and desired outcome.. 
Keep in mind, that following the advice from a surgeon on this or any other website who proposes to tell you what to do based on two dimensional photos without examining you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of each operative procedure may not be in your best interest. I would suggest you find a plastic surgeon certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person.  
 
Robert Singer, MD  FACS

La Jolla, California

How would I benefit from over the muscle vs under outside of healing time?

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