Is going over the muscle truly worth risks if it could help with slight ptosis ? (photos)

I have slight ptosis and am getting 375cc silicone implants. My doctor recommended going over the muscle to help with the ptosis, and also lowering my inframammary fold to allow for more lower pole fullness. I would prefer to go subpectoral, or "dual plane" to get the benefits of partially under the muscle on top and sub glandular in my lower pole.. But I feel strange going against his recommendation of over the muscle. Can I get away with under without my nipples/tissue sagging?

Doctor Answers 21

Over VS UNDER the Muscle in Breast Augmentation??

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You are absolutely right.

A well chosen implant placed in a subpectoral Dual Plane customized pocket with a Breast Lift, IF NEEDED, is THE way to go for a long lasting result. As regards your surgeon, I do think you should discuss it with him but proceed only after your questions are fully answered to YOUR satisfaction.

Good Luck


Memphis, TN

Memphis Plastic Surgeon

Is going over the muscle truly worth risks if it could help with slight ptosis ?

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you for the question and your photos. It would be
difficult to fully assess your situation without an in-person examination. What is necessary to raise the inframammary fold will depend on the specific patients situation. In women with thick layers of breast skin, fat and glandular tissue there is good padding to cover breast implants. In such women, the additional padding provided by the pectorals major muscle may not be critical. Most board-certified plastic surgeons believe, based upon clinical studies regarding placement of the implant and contracture rates, that placing the implant below the pectorals muscle(subpectoral), reduces the the rate of capsular contracture, when compared to (subglandular) above and over the pectorals muscle. Visit few more board-certified plastic surgeon and get more recommendations and understand the advantages and disadvantages of subglandular vs. subpectoral and have a full evaluation. Best of luck. Dr. Michael Omidi. An
in-person exam with a board-certified plastic surgeon is the best way to assess
your needs and provide true medical advice.

Michael M. Omidi, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 120 reviews

Is going over the muscle truly worth risks if it could help with slight ptosis ?

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Please understand that my comments are based on an examination of the 2 photos you submitted, and might be different following an in-person consultation. It appears to me that your nipples are positioned above the inframammary folds. It should be possible to obtain a nice result with a dual plane subpectoral breast augmentation alone, without doing a breast lift. I want to echo the comments of my colleague who cautioned against lowering your folds; this would almost certainly lead to double bubble deformities and all kinds of headaches. Keep in mind that there is no harm in seeking another opinion. Good luck.

Over or under the muscle

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 Hi and thank you for your question. Based on the photos you've provided your nipples appear to be in a relatively good position. You appear to be an excellent candidate for a dual plane breast augmentation . My suggestion is that you schedule additional consults before you commit to a procedure that you do not seem to be comfortable with. Consider finding a practice such as ours that uses the Vectra 3-D imaging system.  We can use this to give you a very good idea of what your breast will look like with implants in place. I think we can demonstrate that your nipple position should be excellent  in the dual plane position. Also bear in mind that there are several modifications to the dual plane procedure. These modifications can be used to improve the nipple position in patients for whom where we are trying to achieve more elevation. 

Dr. West 

Justin West, MD
Newport Beach Plastic Surgeon
5.0 out of 5 stars 30 reviews

Going over the muscle and lowering the fold?

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You really need to get more recommendations as both going over the muscle and lowering your inframammary fold would not be recommended by most board certified plastic surgeons; you risk major complications and multiple future revision surgeries. Please see examples of vertical mastopexy and breast implant augmentations in below link. Have you asked your surgeon to show you a series of patients who may have undergone the surgery he/she is recommending? You can contact our office if you would like a more detailed explanation.

Arian Mowlavi, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 106 reviews

Is going over the muscle truly worth risks if it could help with slight ptosis ?

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Based on your photos, it does not appear that you have breast ptosis. However, you do appear to have mild pseudoptosis. I would not recommend lowering your inframammary folds. This may result in double bubble deformities. This could also result in implant malposition or bottoming out. I'm not sure why your plastic surgeon feels that you need more lower pole fullness in your breasts. This would make your breasts look even more saggy. Whether you have your implants placed above the muscle or below, or in dual plane pockets is best determined after an in person examination. Thank you for sharing your photos and questions. Best wishes.

Dr. Gregory Park

Gregory Park, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 176 reviews

Breast Augmentation: information

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Dear Tatiana2016,

Thank you for your story and photos.

It's always best to ask your chosen Plastic Surgeon these questions yourself. It's not only ok but your right to be informed.  Don't feel "strange" to understand the rationale of what's happening with your breasts

Unfortunately without a examination I can advise you in general terms, however I hope you will find them helpful.

1) I strongly recommend a dual plane. Why?
a) pectoralis mucle provides coverage of implant
b) lowest incidence of capsular contracture

2) correction of breast Ptosis by lowering inframammary fold by definition results in a lower position of the breast mound and sometimes can result in a desired result but can also lead to:
a) "double bubble" deformity
b) "bottoming out"

3) I recommend that you look to the long term result rather than a short term compromise.

My recommendation
1) collect "model" photos of what YOU WANT.
2) if you requires a mastopexy (lift) so be it.

I recommend you have another appt with your chosen Pladtic Surgeon. I trust  that you have chosen a Plastic Surgeons who is experienced and Certified by the American Board of Plastic Surgery. In addition ideally they are members of the American Society for Aesthetic Plastic Surgery (denoting by membership as having met additional criteria and a focus on Cosmetic Plastic Surgery).

I wish you my best and success,

R. A. Hardesty, MD, FACS
Diplomate and Certified by the Am. Bd. of Plastic Surgery
4646 Brockton Ave
Riverside, Ca 92506
(951) 686-7600

Is going over the muscle truly worth risks if it could help with slight ptosis ?

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Dear Tatianna2016,
I don't think sub-glandular placement is worth it to correct mild ptosis. Patient's with mild ptosis are definitely the most challenging when if comes to surgical planning. It I am not 100% sure at the time of the pre-op whether a patient will need a lift or not I prefer to have a long conversation about goals, preferences, and what my patient is okay with regarding a mastopexy being done intra-operatively. Another option that can help with borderline ptosis is using an anatomic implant, so you might want to discuss this as an option as well.
Best of luck,

Stacey Folk, MD
Denver Plastic Surgeon
4.8 out of 5 stars 25 reviews

The only certain way to address ptosis and sagging is with a breast lift

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It's important to note that the only direct way to address ptosis or sagging of the breasts is with a breast lift.  Having said that, there are many instances in which we can still get a very nice result with breast augmentation alone, as long as it is performed well.  If you go that route, just be aware that you may still have some residual ptosis and need or want a lift later to accomplish your goal if your goal hasn't been met by breast augmentation alone.

If we are going to try to address ptosis with breast implants alone and no lift, then I think it makes sense to consider either a dual plane placement or a subglandular, above the muscle, placement of implants.  You have correctly pointed out that the subglandular placement carries with it certain risks, including increased ptosis over time as more stretch and tension is applied directly to the tissues by the implants, increased palpability and visibility of implant surface changes and ripples, increased visibility of the implant contour and a more obviously round or "fake" appearance, and increased risk of capsule contracture.  It is precisely for those reasons that I very rarely, if ever place, implants above the muscle.  I will if directed by my patients and all other things considered there is no medical contraindication, but it is not my preference.  Conversely, I almost always us some degree of dual plane dissection on everyone; some ladies with worse ptosis get a more aggressive dual plane dissection, but it's still under the muscle at the top.  In my experience, a well done dual plane augmentation rivals any subglandular placement that I have seen or done.  It's sort of like you get the best of both worlds.  It takes a little more time in the OR, but I definitely think it's worth it.

If you are adamant about going above the muscle, I would at least suggest a textured implant, and most likely a shaped textured implant at that.  This would be the best way to at least mitigate some of the risks I mentioned above such as overly round shape, capsule contracture, and rippling.  This is because the shaped implants are highly cohesive gel and not as likely to ripple or appear round, and the texturing helps reduce the risk of capsule contracture.

In the end, if you are unsure about the recommendations of your surgeon, I think there is nothing wrong with obtaining another opinion, or two or three more, just to be sure, but in person, not just online here, because we here can't really examine you and give you the best information.  You should visit only board certified plastic surgeons who have experience with breast augmentation using all types of implants and techniques, as that way you'll be sure to hear about all of the options available and pick the best one for you.  In addition to being certified by the American Board of Plastic Surgery, your surgeon should also voluntarily participate in the Maintenance of Certification program administered by that board. This is the best way to know that your surgeon not only has the best training and experience for the procedure, but that he or she has maintained currency in the certification requirements as opposed to practicing on a "lifetime" certificate which has only been reviewed once at the beginning of his or her career. For more information on this you can visit or Good luck.

Joseph L. Grzeskiewicz, MD
San Diego Plastic Surgeon

Subglandular Placement is a Short Term Fix

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It's not worth it. You are right wanting a sub pectoral placement of your implant. Examination will determine your best mastopexy, circumareolar versus circumvertical/lollypop.

Best of luck!

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