Under or Over the Muscle? Lift? Breast Augmentation. Doctor says under will not give me upper fullness (Photo)

I've always been told and thought that to get the most realistic looking breasts with an augmentation that you needed to go under the muscle. I'm 38, very athletic, have nursed 3 kids and have drooping breasts without much fullness. I desire a full B small C. The doctor suggested going over the muscle with the implants to give me more fullness in the upper breast and wanted to avoid doing a lift. He said I had enough breast tissue to make it look good. I'm looking at 215cc & 235cc sil. moderate

Doctor Answers 11

Under or Over the Muscle? Lift? Breast Augmentation. Doctor says under will not give me upper fullness (Photo)

You have excellent breast anatomy and do not need a breast lift.  However the opposite of what you have been told is true.

Breast implants placed under the muscle will give you more fullness above the nipple than a subglandular implant on top of the muscle.  In addition with the implant under the muscle there is less chance of capsular contracture and visibility of the implant.  Placing the implant on top of the muscle is much easier and my suspicion is that that is why your surgeon recommended a subglandular augmentation.

I suggest you obtain a second opinion.

What size should you get?

It is very difficult to determine the best lift you will need (recommended based on your photos) or the exact size and shape implant you will require to best match your ideal breast image without an examination by a board certified plastic surgeon. Not just any board certified plastic surgeon, but one with many years of frequently performing breast augmentation surgery including different approaches, techniques and implant choices. This is because several measurements not to mention your breast characteristics are needed to determine the optimal implant size to obtain your goals. Without knowing these dimensions it would be difficult to make this determination. For example, the existing base width of your breast will determine, in many cases, the maximal volume per implant profile that you can accommodate. To illustrate; a 100 cc difference may make a significant difference with a narrow base width breast, but much less of a difference if you have a wide chest wall and wide breast “foot print”. Therefore, just because your friend may have a great result with let’s say a 300 cc implant to make her go from a “A” cup to a “C” cup size does not mean that you will have the same result with the same size implant. The same process goes for just filling in the upper part of your breast without becoming much larger. Further simply placing implants in a bra to determine the size best for you is not always accurate as the bra often distorts the size, is dependent on the pressure the bra places plus the implant is outside your breast and not under it among other variables. Computer software morphing programs that automatically determine the best implant size can be helpful in some but not all cases (e.g. doesn’t work well in my experience with existing implants, sagging or asymmetric breasts). Using “want to be” photos however are useful if simply provided to the surgeon as I will further explain in the link below including silicone vs saline implants

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 157 reviews

Breast Implants Under the Muscle

Only in rare instances would I suggest implants on top of the muscle and likely never when using silicone implants.  The data has shown a much higher rate of capsular contracture in the subglandular position with silicone.  Plus the instance of implant edge visibility and rippling is greater with implants on top of the muscle.  You have the anatomy to have an excellent result without a lift and have chosen a reasonable implant size to accomplish a one cup enhancement.  If you would like a complimentary second opinion call (205)980-1744.  I can see you this week.

Christopher J. Schaffer, MD
Birmingham Plastic Surgeon
4.8 out of 5 stars 116 reviews

Under or over the muscle?

Thank you for sharing your excellent questions and photographs.  I think you are starting from an excellent position and can obtain a nice, natural result with breast implants alone.  I would recommend placement of implants beneath your muscles as this leads to a more natural look and feel while trending towards fewer complications.  Hope this helps.

Nelson Castillo, MD
Atlanta Plastic Surgeon
4.9 out of 5 stars 68 reviews

Under or Over the Muscle? Lift? Breast Augmentation.

Thank you for your question. Based on the picture you do not need lift. You are a good candidate for breast augmentation. I recommend to have under the muscle and that gives better outcome. 

Ven Erella, MD
Austin Plastic Surgeon
4.9 out of 5 stars 32 reviews

Upper breast fullness

I would tend to disagree with your doctor on several points.  Of course, my opinion is based on photos and he has had the benefit of a personal examination.  First, I don't think you need a breast lift at all.  You may have lost some volume in your breasts after breast-feeding, however, the overall shape of your breasts appears fine.  I also think that you can get an excellent result whether you go over or under the chest muscle.  Unless he is planning to use a textured surface implant or acellular dermal matrix (ADM), placing an implant over the muscle may increase the risk of capsular contracture.  You would also lose the benefit of the additional tissue (muscle) coverage over the implants thus making ripples/wrinkles more of a possibility.  I started my career doing only above muscle augmentations, however, I have changed my philosophy over the years and now I do most of my augmentations under the muscle.  It takes a bit longer to reach the end point to your results but I think it is worth it in the long run.

Edwin C. Pound, III, MD
Atlanta Plastic Surgeon
4.6 out of 5 stars 25 reviews

Breast augmentation

Hello and thank you for your question. There are several advantages and disadvantages to over vs under the muscle.  Under the muscle has the advantage of lower capsular contracture rates, less risk of rippling, and better visualization with future mammograms.  Most patients say that under the muscle also has a more natural look and feel.  The size, shape, and profile of the implant is based on your desired breast size/shape, your chest wall measurements, and soft tissue quality.  This decision should be based on a detailed discussion with equal input from both you and your surgeon.  This entire surgery can be performed with a small incision technique.  Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.  

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Richard G. Reish, MD
New York Plastic Surgeon
5.0 out of 5 stars 131 reviews

Should work

The USA is king of submuscular implant placement. Many other counties do subglanduar with very nice results. For the right patient it is a very good option as long as you realize higher capsule rates and mammograms not as good. Good Luck!

Gregory T. Lynam, MD
Richmond Plastic Surgeon
4.9 out of 5 stars 59 reviews

Upper pole fullness

Thanks for the great question and the photos. I typically use a lot of measurements to determine the ideal implant size to provide my patients with natural results. In my opinion, looking at your photos, you may be able too get the results you desire with a breast augmentation alone. It's my preference to place implants underneath the muscle as it provides a more natural result because a portion of the implant is concealed by the muscle. In very athletic patients such as yourself, placement of the implant under the muscle should provide you with a natural looking breast that still has upper pole fullness. I hope this helps and best of luck!

~Dr. Sieber

David A. Sieber, MD
Bay Area General Surgeon
5.0 out of 5 stars 34 reviews

Breast Implants/Breast Augmentation/Anatomic Gummy Bear Implants/ Silicone Implants/Breast Implant Revision 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

Jaime S. Schwartz, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 93 reviews

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.