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

Question

I have dense "D" cup breasts with sagging and ptosis. I am getting a breast lift with Sientra high profile implants, 695 cc on one side and 655 on the other. The doctors I have seen measured my breasts 27 cm and 30 cm on the other. One doctor said I have plenty of tissue, so I should consider over the muscle placement. The other doctor said he would put the implant under the muscle so they will look more like my own breasts. What is the general consensus for implant placement in dense breasts?

Luis Villar, MD, FACS · Answer

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

Ronald J. Edelson, MD · Answer

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.

Sepehr Egrari, MD, FACS · Answer

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.

Judith M. Gurley, MD, FACS · Answer

I am curious as to what is your goal? larger breasts? better shape? better position? Placing this size implant into D cup breasts will likely increase your size by several cup sizes. The concern is melding large breasts with large implants. It's tricky to get a natural union of the two structures. Going that large in size can cause disproportion of your figure so be careful. Most women do not want to look heavy and implants that large could cause you to look overweight. Sometimes D cup breasts can look fuller with a "lift" rather than an implant. If superior pole fullness is the goal, a lift with small implant can often achieve that.
	So exact position of implant, and I do not recommend textured or a shaped implant, it is less important than size and shape. But my preference would be, without seeing you, sub muscular.

Naveen Somia, MBBS, PhD, FRACS · Answer

An implant placed under the muscle using a dual plane technique will give a natural look and have a reduced incidence of complications. The major disadvantage of placing the implant under the 'dense breast' is the risk of the breast drooping over time creating an unnatural appearance

	Hope this helps

Tom J. Pousti, MD · Answer

I think it is in your best interests (and that of most patients seeking breast augmentation surgery) to have implants placed in the “dual plane” 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 in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position.
	  

	The sub muscular (dual plane) breast implant positioning does have the potential downside of “animation deformity” ( movement/ distortion of the breast implants  seen with flexion of the  pectoralis major muscle).
	 

	Again, I think the advantages of sub muscular (dual plane) breast implant placement far outweigh the  potential disadvantages associated with breast implants  placements of glandular position,  no matter how "dense" the patient's breast tissue is.

	I hope this (and the attached link) helps.

Steven Wallach, MD · Answer

I prefer placing implants under the muscle when a person has dense breasts or without a lot of tissue.

Shaun Parson, MD · Answer

Thanks so much for your question. I think it is always better to place the implants under the muscle. If you are having a breast lift I don't understand why a surgeon would recommend not going under the muscle. Typically the only situation were the implants would be places on top of the muscle would be if you had no lift. This will give you a short term result that is reasonable but it can lead to even more drip with time.

Remus Repta, MD · Answer

Hello,

	Thank you for the question.  There are several factors that determine placement of the implant in breast augmentation including: patient and surgeon preference, thickness of breast tissue, desired goal, and breast animation.  Breast augmentation under the muscle requires the release of the muscle so only a portion of the implant is actually under the muscle.  You will need to discuss all of these issues with both of the plastic surgeons that you have consulted with.  There may not be a wrong or right answer rather which pro's and con's are most important to you.

	All the best,

	Remus Repta, MD

Alan M. Engler, MD, FACS (retired) · Answer

1) Read Dr. Villar's response

	2) I am generally concerned about adding breast implants to a mastopexy for someone who is a D cup (assuming you're truly a D) and who has dense breast tissue.  The risks are greater (than with looser tissue) and one could reasonably ask why you don't just have a breast lift alone?

	3) Even if you want the enlargement, I would urge you to stage the procedure.  This usually means doing the breast lift first and then coming back several months later and having the implants put in.  Aside from being much safer you could arguably wind up with a better result aesthetically.

	I hope that this helps and good luck,

	Dr. E

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

Answers (11)

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