Do I Need a Lift/Advice Benefits of Going over the Muscle? (photo)

Hi,I am currently looking to have a breast augmentation but wondered do i need a lift. I have had different consults with different opinions. I have also been advised I have enough tissue to go over the muscle, but regardless of how much tissue I have isn't under the muscle more beneficial. I get the feeling from my last doctor he wants to make this really EASY, but i want long lasting results. I am currenltly leaning toward saline over the muscle. I am 31years old, 2 kids 112lbs. Please help!

Doctor Answers 26

Benefits of Going Over Muscle #breastimplants

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A few things I did not get was how large you want to be. That may affect whether you need a lift or not. So there are so many things with regards to saline or silicone above or below the muscle. I feel that a better long term result will be in the sub-muscular pocket. Capsular contracture rates are higher above the muscle and higher with saline above the muscle vs silicone. Below the muscle the contracture rates are the same for either silicone or saline. Above the muscle you will find more rippling of the implant with saline above the muscle than below the muscle. Your tissue will thin over time and with implants above the muscle you will surely have a great amount of visibility of the implant. This can happen with either silicone or saline but is more common with saline. 

As to the lift. If the nipple is at or above the fold usually you do not need a lift, but if you have part of the breast tissue below the fold, pseudootosis, like you do sometimes if you do not go big enough you will need the lower breast skin removed. The lower pole of the breast is the worst part of the breast in my opinion in terms of quality of the tissue and skin. When I perform an augmentation and lift I usually get rid of that lower pole breasts skin and some tissue so the breast does not bottom out over time. The lift part is more of a physical exam call and how big you want to be. Bigger implants fill the skin envelope out better. 

Scottsdale Plastic Surgeon
5.0 out of 5 stars 54 reviews

Lift? Not yet. Saline above muscle? NO!

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Though my headline seems more definite, the answers my colleagues are giving indicate that there is no clear-cut consensus and therefore no "right" or "wrong" answer. Yet, the majority of us feel that saline implants have a higher likelihood for visible/palpable rippling, not to mention deflation risk (re-operation), and (above the muscle) a scientifically-proven increased risk of capsular contracture (big re-operation, and one that doesn't always "work").

Yes, there are issues with below-the muscle placement (activation distortion--less likely with proper muscle fiber release, and possible "double-bubble" if crease position is not chosen quite carefully), but the advantages of softer, more natural "feel" and less risk of capsular contracture far outweigh the disadvantages, IMHO. And silicone can never "leak."

You are young, slim, attractive, and don't need the increased scarring (probably) of a lift right now. (Unless, of course, your nipples are below the level of your inframammary creases, which is impossible to accurately determine from your photographs. Try an arms-down pencil test--if your nipples are below the level of the pencil held at your crease level, then you DO need a lift, not just large implants above the muscle.) But if your nipples are at or above the pencil level with your crease, expert augmentation alone may well yield not only satisfactory but superior cosmetic results, without the scars, cost, and increased risks (slight) of a lift plus implants.

And of course, a lift can always be added later if needed--In borderline cases such as yours appears to be I actually recommend augmentation first, and see if in fact it works out to my patient's and my expectations. If not, then I can "add" the lift as a second operation, but do so for the difference in cost between an augmentation with implants alone and a lift plus implants. That takes the financial disincentive of two operations out of the equation, though of course, the patient understands that a second operation and recovery is needed. But neither of these operations is really that tough on our patients!

Still, if you start with a lift plus implants, you'll never know if an augmentation alone (without the increased cost and scarring of a breast lift) was ever possible to give an aesthetically-satisfying result, won't you? You pay more, get much more scarring, but (usually--there is still always a small risk of possible need for re-operation) it's a one-operation and recovery procedure.

Think about this and perhaps get another opinion or two--any surgeon who would choose the "easiest" over the "best" is not going to get my vote of approval! Since none of us surgeons is "perfect," we had better always try for the best, since we can fall short on occasion. But that's why I think the factors above bear consideration. For several examples of women with moderate to significant ptosis (droop) for whom I performed augmentation alone without lift (all dual-plane submuscular/subfascial), click on the web reference link below and check out cases 5, 6, 11, 24, 27, and 31. Best wishes! Dr. Tholen

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
4.9 out of 5 stars 263 reviews

Breast Implant Placement

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Hello Marie,

You are very astute with your feeling that the doctor wants to make this as easy as possible FOR HIMSELF.  There are two issues going on here, one is the need for a lift or not, and the other is implant placement above or below muscle. Unfortunately these two issues are sometimes linked together (placement above muscle will negate the need for lift), but this is incorrect, despite many surgeons (and patients) believing this to be true.

Women with your breast appearance are at risk for being told that a large, usually high profile implant placed over the muscle is 'all you need to look great'.  The reality is that it is unlikely to work for a majority of women, and that even those that look acceptable initially are likely to develop issues after a short period of time.

My advice to you is to get a dimensional analysis of your chest by a breast specialist who is certified by the ABPS and a member of the ASAPS. This will allow the surgeon to choose the appropriately sized implant.  Planning of the surgery will include implant placement in a subpectoral position, and the addition of a breast lift to achieve a normal breast contour.  Although some of the other doctors have said that your breasts don't have much ptosis, the reality is that a thorough physical exam is needed to determine this. However, I believe based on your photos that your nipple is clearly below your fold, and that is with your arms partially elevated.  With your arms at your side, it would be even lower.

Best of luck!

Gerald Minniti, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 100 reviews

Lift with implants

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This is what I do to maximize lift with a breast implant alone:

- use silicone cohesive gel implants. The more cohesive the better. I am not sure if these are available yet in the US, but the Allergan Inspira Truform 2 implants are ideal

- use high profile implants. The more projection you have, the more lift you will get

- have the implants placed in the submammary pocket (under the breast itself). You should have a pinch thickness at the top of your breast of at least 2 cm

Please see an experienced board certified plastic surgeon to find out whether you are a suitable candidate. Best of luck.

Over versus under the muscle with lift

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Hi, placing the implants below the chest wall muscle greatly reduces your risk for capsular contracture (hardening of the breast requiring more surgery). Also, by placing the implants below the muscle there is less risk of being able to feel the implants. Although, gel implants feel more natural than saline implants. Also, the larger your implants are, the more risk you will have for sagging of the breast. When the nipple is below the fold of the breast, a lift will give a nice shape so that implant lies in harmony with the breast.

Most women need lifts

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You need silicone implants placed retro-pectoral.  They give the most natural appearance and feel.  You definitely need a lift.  This can be done leaving only a scar around the areola.  The goal of this procedure would be to lift your areola, lift your breast tissue and place implant high on the chest wall.  Aligning all 3 in the same horizontal place will provide maximum projection and give you a more attractive appearance.  You are a perfect candidate for a new technique called Breast Augmentation with Mini Ultimate Breast Lift.

Best Wishes,

Gary Horndeski, M.D.

Gary M. Horndeski, MD
Texas Plastic Surgeon
4.6 out of 5 stars 230 reviews

IMPLANTS first and LIFT later

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Choosing an implant size that is a little larger (think around 400-450cc or more) in size may give you the look you want.  With your size of breasts and the nipple position, why don't you get the implants, let them settle for 1 year and then decide if you want the nipples higher.  Under the muscle is the very best choice for many reasons.  First, they will look more natural with a muscle covering, less rippling, and more protection for the implant.  Hope this was helpful and as always be sure your surgeon is boarad certified to do plastic surgery.  Board Certified Cosmetic Surgeon is NOT a legitimate board.


Breast implants

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I feel that you need a lift as well as implants.  If you are using saline implants, you definitely want them under the muscle.  If they are above the muscle, you are likely to see some rippling of the implant under the skin.  

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 29 reviews

Lift or sublgandular augmentation

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Based on your pictures, you do have some post child bearing droop to the breasts. In all cases I never recommend sub-glandular saline implants. It is too likely that you will have visible or palpable rippling or wrinkling of the implant. I would probably recommend a sub-glandular silicone implant to fill out the deflated tissue and give you the most natural result. If you were very interested in a a sub-muscular approach I might recommend a small lift (peri-areolar) to centralize your nipples on the breast and prevent the appearance of droop of the breasts off of the implant. I hope this helps.


Daniel Medalie, MD

Under the Muscle for a Long Lasting Result

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Based on your photographs, a breast lift is not necessary. I would recommend saline or silicone gel implants under the muscle for a long lasting result with the fewest complications and risks. Good Luck!

Donna Rich, MD
Webster Plastic Surgeon
4.5 out of 5 stars 33 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.