How do I choose between over muscle and under muscle? (Photo)

Question

ive had 2 consults hoping to help me decide . the consults left me even more confused. First surgeon recommended a lift, utm and saline implants because i have alot of breast tissue. 2nd surgeon recommends a otm silicone implants and mesh with a lift . how to decide over , under, saline, silicone, mesh or not. thanks for any advice. im a 60 year female with lots of sagging

Ramin Behmand, MD, FACS · Answer

Choosing the right procedure for breast rejuvenation can be complex, especially with the varying recommendations you've received. Here are a few key considerations to help guide your decision:

1. Breast Lift (Mastopexy): Given the significant sagging present, a breast lift is the most beneficial portion of the surgical plan. This procedure can correct the sagging by removing excess skin and reshaping the breast tissue, which will provide substantial improvement in breast appearance.

2. Implant Type (Silicone vs. Saline): Silicone implants are generally preferred for their more natural feel and appearance. They are also less likely to cause rippling compared to saline implants.

3. Implant Placement (Over vs. Under the Muscle): Placing implants under the muscle is favored for several reasons, including a lower risk of capsular contracture (a common complication where scar tissue forms around the implant), better imaging during mammograms, and often a more natural appearance.

4. Long-Term Considerations: Implants are not lifetime devices and will likely need to be replaced at some point. Considering your age, this is an important factor, as any subsequent surgeries will be undertaken when you are older.

5. Alternative Options: If you're uncertain about implants, you might initially opt for just a breast lift and then assess your satisfaction with the results. If more fullness is desired afterward, you could consider a second procedure for implants or explore fat grafting for a more natural enhancement.

Finally, choose a surgeon with whom you feel comfortable and who understands your aesthetic goals. A third consultation with another experienced surgeon might also provide clarity and help solidify your decision.

Timothy M. Rankin, MD, FACS · Answer

If you are getting breast augmentation with breast implants, the implant will be placed behind the chest muscle in most cases. There are a few exceptions where the breast implant is placed over the chest muscle due to the activity level you may enjoy. 
At NorCal Plastic Surgery, we use gummy bear implants, which are smooth, round implants that will enhance the appearance of your natural breast, safely. They are among the safest and most commonly used implants for breast augmentation. 
Breast implants do not cause breast cancer or any other systemic diseases. Numerous studies have shown no difference in survival between augmented and nonaugmented patients with breast cancer. Studies have also shown you may continue your recommended breast cancer screening with mammograms or any other technology recommended by your primary care physician.
There are also a few options for placement of the incision, such as under the armpit, along the border of the areola, and under the breast. During your initial consultation, we will determine implant placement and incision type.

Sacha Obaid, MD · Answer

Hi there.  Thank you for your photo and question.  I have included a video to describe the difference.  Hope this helps to answer some of your questions.  Best of luck!

Daniel Barrett, MD · Answer

Dear what2do,
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, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Ted Eisenberg, DO, FACOS, FAACS · Answer

Implants do no lifting. They only make you fuller and bigger, if that's your desire.  After I measure and discuss goals with my patients, we then look at pictures of women (my patients) with similar measurements with different size breast implants. They also get to see what they would look like when the breasts have fully dropped and fluffed and in clothes. You get to see actual results and the surgeon' s experience and not a virtual idea of what can be achieved. Women tell me that this process is very helpful in determining what is right for them. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Gary M. Horndeski, MD · Answer

Your breasts are very ptotic and do not need implants. What you need is a breast lift using The Bellesoma Method. This will reshape your breast tissue creating upper pole fullness without implants, elevate them higher on the chest wall and more medial to increase your cleavage. Vertical scars are avoided, nipple sensation (in 95%) and the ability to breast feed are maintained. Later, fat transfers can be performed if additional volume is desired.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Paul E. Chasan, MD, FACS · Answer

Thank you for your question. I have been in practice almost 30 years and breast revision surgery is a large portion of my practice. I have a whole gallery titled "long-term changes associated with implants placed on top of the muscle ".  I have seen so many patients who have had implants on top of the muscle and they all suffer from the same thing, slide down of the implant on the chest wall.  There is nothing to prevent the implant from sliding down the chest wall.  I completely disagree with the other doctors answer. In your case, you would benefit from a surgery that I actually pioneered and published in 2017 termed "reductive augmentation ".  This includes performing breast implantation-under the muscle, breast lifting, and removal of inferior pole breast tissue.  You are an excellent candidate for this procedure.  Best wishes to you.

Shlomo Widder, MD · Answer

Dear Virginian,
   Thanks for posting your pictures. From observing your picture you appear small C or full B cup size with level 3 ptosis (droopiness). You did not mention your desired cup size, however, based on my 37 years of practice, women at you age do not request large breasts. So, in my opinion you will be very happy with just a full lift procedure (Key hole)  of your breasts. Obviously, if you desire larger breasts, that will require breasts implants, which I would recommend Saline implants placed under the muscle for many reasons which I can explain to you in person.
    Always, consult with experienced board certified plastic surgeon who operate in accredited surgery center for your safety. Most importantly, check the before and after pictures in the photo gallery to make sure that they are numerous, consistent and attractive with nice cleavage, nice scars, symmetrical and natural looking.
               Best of luck,
                             Dr Widder
                   widderplasticsurgery.com

Ronald J. Edelson, MD · Answer

I would recommend something different. Get the lift first and then at a second stage the implants can be placed. You will have a hard time getting a good result if you try to do the lift and implant s at the same time. Mire and more surgeons are doing cases like this in two stages

Ram Kalus, MD, FACS · Answer

Thank you for your question and photo. A definitive recommendation can only be made after an in-person evaluation. That said, in order to achieve a satisfy aesthetic outcome with which you would be pleased you absolutely need a breast lift. In my opinion and extensive experience, in order to achieve the best long lasting outcome your implant should be placed above the muscle to help avoid a “waterfall deformity” wherein your implant is high and your breast “falls off” the implant long term. You should not need a mesh with a properly performed breast lift. Furthermore, based on your photos, it appears that you may have adequate breast tissue volume to possibly avoid an implant. If you choose to be augmented with an implant it should most likely be a relatively small (maximum 275 cc) moderate (low) profile or “classic” projection with adequate width (base diameter) to properly fill out your breast skin envelope.

Continue to do your research and consult with an experienced board certified plastic surgeon who can advise you on your options. AlSelect your plastic surgeon based on his or her reviews, the Before and After gallery, and your gut feeling about the surgeon and the office staff. Best of luck to you.

Continue to do your research and consult with an experienced board certified plastic surgeon who can advise you on your options. AlSelect your plastic surgeon based on his or her reviews, the Before and After gallery, and your gut feeling about the surgeon and the office staff. Best of luck to you.

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