Is It Better for an Implant to Go over or Under in a Tubular Breast?

Hello! Thank you for your question! Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts. Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years. In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance. Your breast width is the most important measurement. Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant. This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape. Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width. Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later. Very slightly less tissue may be visualized with subglandular implants, but not very significant.  Above would be the better option, as work on your tissue would be done at the same time.  Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle). Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each. In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome. A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles. Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions. As you see, there are a few factors to decide upon for incision, placement, and implant type/size. Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits. Hope that this helps! Best wishes for a wonderful result!

Is It Better for an Implant to Go over or Under in a Tubular Breast? Generally, I prefer to the dual plane approach in which the gland is released above the muscle but the implant is placed below it.
 

Tubular breasts are a difficult problem. You can see by the varied recommendations of some of the finest surgeons below that there is no consensus on how to treat them.
In general , we have several theories about tubular breasts.
1. The lower pole of the breast is tight. We must respect that and not try for too large of an implant. Excessive scoring of the breast can kill the nipple or make it insensate. I have personally seen cases where this happened.
2. I prefer under the muscle augmentations with a conservative size, preferably in the dual plane technique.
3. Every effort should be made to correct the asymmetry as much as possible, usually with silicone implants to avoid the inherent differences between saline and natural breast tissue.
4. Lifts are almost always necessary to achieve relative nipple symmetry and reduce drooping.
5. Patients must be realistic. Their breasts will not be perfect with so many changes being made to the breast at once. Revisional surgeries are common once everything settles down, and an implanted breast ages differently than one with a smaller or no implant, so the breasts will become different over time.
These cases are the graduate course, not Breast Aug 101. You should have the distinct feeling that your prospective surgeon has a concrete plan, has considered all the elements, and is safe.

Hi there-
Because the benefits of placing the implants under your muscle are so compelling, I would recommend this position for you, despite the tubular shape.
Given the tubular shape and your asymmetry, a dual plane technique would be best.

Hello - Yes, tubular breasts can be corrected with implants over the muscle. However, if extensive work will be done around the areola you may want to get the implants under the muscle to prevent any blood flow problems to the nipple-areola area. As far as your risk for breast cancer, check with your family physician about getting tested for the gene. You may want to consider a mammogram before any breast surgery as a baseline to compare with future mammograms. Good luck!

I am sure you are aware that the plastic surgeon who examined you is in the best position to give specific advice, but here are a few general statements that may be helpful: Since you are concerned about breast cancer, most radiologists feel that they get a better mammogram with implants under, though how much better is subject to debate.
On a practical level, when implants are placed with a breast lift at the same time they usually go under, since the blood supply is preserved better that way. Tubular breasts typically have a some version of a lift involved but not always. One thing that I have found useful with tubular breasts and asymmetry is the use of expander implants, a type of saline implant (Spectrum from Mentor) that is only partially filled at the time of placement.
There is a "port" under the skin below the breast where saline is added by injection in a few sessions over a couple of months after the surgery, and the port is then removed under local anesthesia. This allows for both expansion of the skin on the side where it is tighter, and fine-tuning the size difference for better symmetry.

For most cosmetic indications, breast implants are best placed under the muscle. However, sometimes with tubular breasts you actually get the best result from over the muscle placement or, if placed under the muscle a dual-plane II technique to radial scoring of the breast tissue. I hope this is helpful.

Thank you for the question.

Tuberous ( constricted) breasts are characterized by a wide spectrum of presentation including constriction of the breast base, glandular and skin hypoplasia (especially at the lower quadrants), mal-position of the infra-mammary fold, breast tissue herniation into the areola region and sometimes increased areola diameter. 

Generally,  correction of tuberous breast anomalies involves breast augmentation with areola reduction / mastopexy procedure. The distance from the inframammary fold is increased (to create a more rounded out appearance). Proper implant positioning improves the distance (cleavage) between the breasts. The areola reduction helps to treat the pointed and "puffy" appearance of the areola.

In the most severe cases of tuberous breast, a more complete breast lift may also be necessary.  In many cases however, a lift is not necessary. The patient should be aware that the final result will take months to see and that they will need to be patient and that revisionary surgery is more likely than in patients who do not present with tuberous (constricted) breasts.

Although every surgeon may have their own preference,  I would prefer to place the breast implants in the sub muscular (dual plane) position  if at all possible  to minimize risks associate with breast implants placed in the sub glandular position.

Probably more important than breast implant positioning,  is selection of a surgeon who has significant experience treating constricted/tuberous breasts. 

I hope this, and the attached link, helps. Best wishes.

I prefer in most cases to place implants under the muscle in a dual plane approach( the lower part really under the breast tissue).

For individuals with a tubular breast on both sides, in general we would recommend a submuscular implant. The reason is that the breast is small by nature, and has a tightness below the nipple and smaller diameter. The submuscular implant gives better cover and keeps the implant hidden as the skin relaxes and thins over the implant. Often we use a round block suture around the nipple to reduce the forward prominence, also called a 'herniation' of the nipple.
I responded to your last question, and would like to continue with your asymmetry specifically. Other readers can move on. You noted a tubular breast on just one side, and considering the degree of asymmetry, it might be preferable to use a submuscular implant on the 'tubular' side, larger of course, and a smaller implant, subglandular on the 'normal' side. Here the reason is if the implant required is considerably smaller, say a 300cc on the tubular side, and a 150cc on the normal side, the subglandular implant may 'show' too much on the tubular side, and the submuscular 150cc implant on the normal side may to too small to blend in with the breast if behind the muscle; not a good marriage between the two. Therefore the best result may be submuscular on the small side, subglandular on the large side.
One other issue you raise concerning breast cancer screening, a good mammogram can be done with both submuscular and subglandular implants. You need not feel there is a trade-off to made one over the other.
Best of luck.