What are the pros and cons of going over the muscle and under the muscle? (Photo)

I am ready to get implants and I am trying to figure out what will be best to achieve the look I want. Why would someone choose over the muscle? I always assumed that the muscle acted as a bra to the implants but I was told I was mistaken. One doctor recently suggested I have them put over the muscle. I have one bigger then the other and have lost fullness from nursing my 2 kids 3 of the last 4 years. I have attached a pic of me and a wish pic. I'm clueless about it all. Also how do I determine size?

Doctor Answers 10

Submuscular

More lateral look
Lower incidence of capsular contracture with smooth implants
Less interference with mammograms

The above are the benefits of going under the muscle.

Best of luck. 

What are the pros and cons of going over the muscle and under the muscle?

In general, the benefits of submuscular breast implant placement are: Better superior (upper) coverage/hiding the implant in your cleavage where you will show them off the most Much lower rates of capsular contracture or scar tissue build up around the implant Most importantly, breast implants under the muscle do not interfere with your mammogram I, persoanlly do not believe there to be any lasting benefit of subglandular (or sub fascial) placement. If your breasts are entirely below the muscle he will recommend a mastopexy (lift), not subglandular placement, to take advantage of the benefits mentioned above regarding submuscular implants. A submuscular implant looks better, feels softer for longer and doesn’t interfere with mammograms, giving you the best chance at early breast cancer detection and highest cure rate should it develop. However, it’s not always that simple. Many times the bottom edge of the pectoralis major muscle ends higher than your natural breast crease. If the placement of breast implants lies completely under the muscle it “rides high” and delivers a less than ideal aesthetic result, with your natural breast “falling off” the front of the implant. Therefore, to prevent that, I frequently utilizes a dual plane implant placement. This means as much of the upper portion of the submuscular implant is under the muscle, for all the reasons listed above, but a small portion of the implant “peeks” out from under the muscle so the implant is nearly centered under the nipple. There are different degrees of dual plane release (I, II, III) but I will do as little a release as possible to achieve an optimal aesthetic result, thereby leaving maximum muscle coverage. 

Several Advantages to Under the Muscle

Although there's no single right answer for everyone, I've found that both doctors and patients alike often prefer under-the-muscle, or submuscular, placement. This placement has been linked to lower rates of certain complications, including capsular contracture. It also makes it easier to visualize the breast tissue during imaging tests, such as mammography. Many people also believe that this placement creates more natural-looking results. This option can also help give you a full, voluminous look in the upper portion of your breasts. However, this approach does usually require a bit more downtime. I recommend getting a few opinions from board-certified plastic surgeons near you to learn more. Best of luck with your decision.

Breast Implants / Breast Augmentation/ Cohesive Gel Implants / Silicone Implants / Revision Breast Surgery

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
Director-Beverly Hills Breast and Body Institute
#RealSelf100Surgeon

What are the pros and cons of going over the muscle and under the muscle?

In most cases I prefer placing implants under the muscle as it provides more coverage and support of the implant. However, it is all relative based on the patients chest and desired outcome. 

Regards, 

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 425 reviews

Implant pocket and size

In most cases, I prefer to place implants under the muscle because it provides more soft tissue coverage in the upper pole. In addition, there may be less risk of a capsular contracture to develop.  Implant volume depends upon your goals and your anatomy which is best determined in person after an exam.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

What are the pros and cons of going over the muscle and under the muscle?

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.

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.

Hope that this helps! Best wishes for a wonderful result!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 24 reviews

Breast Augmentation Placement

Each placement option has it's benefits. The possible benefits of #submuscular placement are that it may result in less palpable implants, decreased risk of capsular contracture, and easier to image the breast with a mammogram. Under the muscle placement is recommend for women are are very thin with very little breast tissue.
The partial muscle coverage will hide the implant better and help avoid visibility of any implant imperfections such as rippling. The appearance will also look more natural.

This #sub-glandular #placement may allow for a shorter surgery and recovery with less discomfort. This placement can provide a slight “lift.” #Sub-glandular placement can result in more palpable implants, increased risk of capsular contracture and more difficult imaging of the breast with mammogram. This placement is often recommended for those patients with mild breast sag, but do not want a breast lift (mastopexy) and for tubular breast deformity.

The #Dual-Plane placement method is a more current technique most often used when there is mild breast sag and the patient does not want a breast lift. The breast tissue and muscle are partially separated to allow the breast tissue to sit in a better position. Dual-plane can be discussed further during the consultation should breast sag be of concern.

It is imperative you select a plastic surgeon who is board-certified and has a great deal of experience with breast augmentation and the incision type, implant placement, and implant type. Plastic surgeons who have specialized in breast surgery and cosmetic surgery are suitable to perform your breast augmentation Aside from checking board-certification, it is suggested that you look at before and after photos of the surgeons actual patients, and read patient reviews. Gathering all of this information will help you make a well-informed decision.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 96 reviews

Implants

I suggest that you meet with a board certified plastic surgeon who can answer all your questions. During the consultation, you will be measured and be allowed to try on a variety of sizes to see what fits your frame and what you prefer. Your surgeon can also best advise you if your implants should be placed behind or in front of the muscle.

Connie Hiers, MD
San Antonio Plastic Surgeon
4.6 out of 5 stars 13 reviews

Pros and cons of going over the muscle and under the muscle?

Thank you for your question. There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”. The vast majority of breast implants placed in the "sub muscular" position are really being placed in the "dual plane" position ( partially sub muscular, partially sub glandular).

I think it is in the best interests of MOST patients (including very active 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 the sub muscular position.

Ultimately, careful communication of your goals (in my practice I prefer the use of goal pictures, direct examination/communication in front of a full-length mirror, in bra sizers, and computer imaging) as well as careful measurements (dimensional planning) will be critical.

Generally speaking, the best online advice I can give to ladies who are considering breast augmentation surgery ( regarding breast implant size/profile selection) is:

1. Concentrate on choosing your plastic surgeon carefully. Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you are looking for. Ask to see lots of examples of his/her work.
2. Have a full discussion and communication regarding your desired goals with your plastic surgeon. This communication will be critical in determining breast implant size/type/profile will most likely help achieve your goals.
In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. For example, I have found that the use of words such as “very natural” or "C or D cup" etc means different things to different people and therefore prove unhelpful.
Also, as you know, cup size varies depending on him who makes the bra; therefore, discussing desired cup size may also be inaccurate. Again, the use of computer imaging has been very helpful during the communication process, in our practice.
3. Once you feel you have communicated your goals clearly, allow your plastic surgeon to use his/her years of experience/judgment to choose the breast implant size/profile that will best meet your goals. Again, in my practice, this decision is usually made during surgery, after the use of temporary intraoperative sizers.

I hope this (and the attached link, dedicated to breast augmentation surgery concerns) helps. Best wishes for an outcome that you will be very pleased with.

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.