Which is Better for Dense Breasts, Implants Placed Under or over the Muscle?

Quality photographs front and side, with arms resting comfortably at your side will prevent you from getting a lot of bad advice from those of us out here trying to imagine what you look like.  (including me).

Here are some general thoughts from treating some really nasty disasters for the past thirty years:

First, if you have very dense breast tissue and require a mastopexy for ptosis on a D size breast, you should consider having the mastopexy performed first without implants.  Dense poorly mobile  tissue makes relocating the nipple-areola complex more difficult with a more tenuous blood supply.

A mastopexy is a tightening procedure. The skin envelope is being reduced with the same amount of tissue which is being forced up into a higher location.  

An augmentation is a stretching procedure.  The two operations are enemies.  Increased pressure lowers the vascular margin of error. Though most surgeons perform both operations simultaneously, the complication rates are higher.  Some physicians consider the loss of a nipple a normal risk and the cost of doing business, but it is a big deal to the patient.

Patients should be carefully evaluated to weed out the higher risk  patients such as those with dense tissue and large amounts of breast tissue, smokers, diabetics and obesity.  

It is prudent to send the patients home with drains in simultaneous mastopexy/augmentations.  If a hematoma develops overnight without a drain the blood supply to the nipples could be compromised resulting in partial or complete nipple-areola necrosis before the morning visit.

Make sure your surgeon sees you the very next day after such procedures.

We have performed 89% of our patients requesting both mastopexy and augmentation in two stages since 1982.  We have not had any partial or complete nipple areola complex losses. No flap necrosis.  One incision infection.  

I would have to examine you to give prudent advice, but the thought of a D size breast reduction and 600cc plus implants raises many red flags to me.

Over the muscle, under the muscle is another complex issue.  Beware of anyone that claims either/or is the only way to go.  There are certain anatomical situations that should never get implants under the muscle.  Best wishes.  Knowledge is power.  Luis F. Villar MD FACS

There is no consensus,although I almost always place the implant under the muscle.  I think the results look better and there is a lower incidence of capsular contracture.

I strongly believe that implants are best suited be placed under the muscle using a "dual plane" techniques. There are lots of advantages to this including better feel and shape, better mammography surveillance, less chance of capsular contracture and infection. Implants above the muscle, especially the massive sizes that you are entertaining, can have a "rock in a sock" look. So, be very careful and make sure you do your home work. Above muscle implants can look good for a few months, but then they start migrating down and taking the breast with them.