I received conflicting suggestions from three plastic surgeons regarding over or under the muscle and volume. Advise? (photo)

I am a 34C, would like to be a D, and don't really want a lift. Ideally I would like sub muscular. I am leery of sub gladular implants due to risks of capsular contraction and mammograms. One surgeon said he could put 360cc silicone implants under the muscle but I might get a double bubble without a lift, another said he would use larger (400/450cc) silicone implants under the muscle using dual plane, the other said he either needed to do a lift or would put them sub glandular with out a lift.

Doctor Answers 9

Under, Over, Size?

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Likely you are getting different suggestions in part because you have clearly indicated that you don't want a lift, so each surgeon is trying to come up with a plan that avoids doing a lift. The bottom line though is that you need a lift, in addition to an implant, to achieve an attractive breast shape. Your photos show that your nipple and much of your breast tissue lie below your breast fold. This is a standard indication for a breast lift. I would also expect that the "pencil test" is positive, i.e. that if you lift your breast up and place a pencil under and let your breast drop back down the pencil will not fall out.

Trying to address your situation with just an implant will only result in an outcome where the breast shape is not attractive because your breast tissue is hanging off the bottom of the implant, or the implant ends up very low on your chest wall without satisfactory upper pole fullness and your breast and implant will be predisposed to rapidly going south over time. It is perfectly understandable that you would not want to have the extra scars and cost associated with a lift, but sometimes you can't get exactly what you want and trying to so just results in a different set on negative outcomes.

Implant position

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Thank you for your post. It is common to hear different plans from different plastic surgeons, almost all of which will end up yielding very nice results for you. Based on your photos, I would tend to agree that placing the implant under the muscle and combining that with a breast lift (mastopexy) would give you the most ideal result. There are trade-offs to each approach, and I'd enjoy hearing more about your goals/lifestyle to better help develop a surgical pathway to get you there. Ultimately, after doing your research, I'd suggest the surgeon that you feel the most comfortable with during the consultations you've had. Best wishes on your procedure!

Implant Placement

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Thank you for your question and photos. The dual plane option may give you enough contact with the implant and your tissue to "fluff" out the deflated appearance of the breast. It is important that you understand limitations of this and that while cohesive gel implants can fill out and improve the fullness of your breasts, this approach will not make you happy if what you want is truly a lift and elevation of the nipple.

It is common for Plastic Surgeons to offer different plans. I recommend that you choose what makes sense to you. Ask lots of questions, ensure that they are board certified and experienced and go with your gut.

All the best

Different paths to the same goal

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As you have heard that there are several different paths that can be followed to get to the same goal.  Both above and below the muscle can achieve a nice result in many cases.  However, as you astutely noted below the muscle has the lowest incidence of capsular contracture, which is why most of us have used that as the recommended position.  When we say below the muscle most of us are referring to a dual plane where most of the implant is covered with muscle but we free the inferior attachments to allow the breast tissue to shift over the implant.  You do have a mild amount of breast ptosis and would have the highest chance of an "ideal" result if you chose to do a small lift at the same time, but you will still have a good chance at a very good outcome with just an augmentation. However, you will have a little lower nipple position than is considered ideal and there is a small chance of having a double bubble deformity.  Many patients are still very happy with the outcome with just an augmentation if they have realistic goals and are expectations. Everything comes with risk and benefits that have to be weighed in your final decision. The easiest and safest way is to do the augmentation with the fact in mind that you may need a lift down the road if you don't get the nipple postition that you are happy with.  When you separate the procedures there is a lower risk of complications in many studies.  However, if you know from the start that you are not going to be happy unless you have a nipple that is in the optimal position then you can combine the procedures to get the best chance at an optimal result in one surgery.  Best of luck on your journey

Breast Augmentation

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We see patients with your anatomy several times a month who decline a lift. The best technique I have found is the dual plane placement using silicone implants. This leaves a very natural look to the breast and there is no reason for a double bubble with accurate implant positioning. There is no benefit to over the muscle.

#breast implants position #dual plane

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The most important factor in obtaining a good result from your cosmetic surgery is the surgeon you elect to perform it.
Be sure you seek the help of a surgeon member of the American Society for Aesthetic Plastic Surgery, this will assure you of the proper credentials of your surgeon.
Patients like you can have a breast augmentation with a dual plane technique with an acceptable result, as long as they understand the the nipple areola complex will be low in the breast, a lot of my patients are happy with that result, if the patient do not like the result, a lift can be perform 3-6 months later.
If the patient wants the nipple to be in the center of the breast mound, then a lift is needed from the beginning, with the resulting scars.
In my practice, the patient choose the size of the implant, using specially designed sizers. My job is to give a professional opinion and point out the pros and cons of their choice. I do not perform on top of the muscle implants for many different reasons, which are explained to the patient in a 45-60 minutes consultation,

I understand your confusion.

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Whenever one goes to different surgeons, you always get different opinions.  Robert Goldwyn, MD a Plastic Surgeon, well respected in his field and one of the previous editors of the Journal of Plastic Surgery, once stated in his book, "The Surgical Note" that "it is difficult to get two plastic surgeons to agree on anything, let alone leaving a burning building at the same time."  

Without a direct, formal examination, it is hard to properly advise you what you need, however, I will be speaking in generalities.

Your breasts exhibit a grade Ia or II ptosis.  This is considered to be minimal ptosis  One can correct the ptosis by many different procedures.

The first, would be an implant places subglandular.  (I wouldn't be too concerned about mammograms.  Capsular contraction can occur independent of the placement of the implant (behind the muscle or under the breast tissue_.  Granted, subglandular implants have a slightly increased incidence of breast capsule formation. If you tell the mammographic technician that you have implants, they will take additional views.

Another technique is to do a duel-plane procedure with a combination of the implant behind the muscle and behind the breast.  Your surgeon will separate the breast from the muscle in the inferior aspect letting the breast "ride-up."

Another technique is to do a lift with implant.  This would result is additional scarring on your breast.

Each of these three techniques depend upon surgeon's preference,  While there is no right or wrong answer you have to chose a surgeon who you trust.

Best of luck, and I hope I removed a bit of your confusion. 

Elliot Duboys, MD, FACS
Long Island Plastic Surgeon

Implant placement and selection

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Thanks for sharing your photos!  That is very helpful for the discussion.

Implant selection is a discussion best had in person with your surgeon, as there will be several factors that contribute. Understanding your goals and setting realistic expectations will be a part of that.

In general, though, implant selection boils down to several things:
1. Shape of implant (round vs anatomic)
2. Size of implant
3. Implant surface (smooth vs textured)
4. Incision placement (periareolar, inframammary, transaxillary, transumbilical)
5. Implant position (submuscular, dual plane, subglandular)

That is too much to go into significant detail here, so let us focus on the implant position, which seemed to be your main concern.  Submuscular placement is extremely rare.  Most often, when people are discussing placing the implant under the muscle, they mean a dual plane.  The dual plane involves lifting the pectoralis major muscle up off the chest so that the top of the implant is behind muscle and the bottom of the implant sits behind the glandular tissue of the breast.  There are several advantages to this placement: there is better coverage for the implant making it less visible and more natural feeling at the top of the implant, there is less risk of capsular contracture, and mammograms may be easier.  The downside of a dual plane is that there may be some animation (or movement) of the implant with contraction of the muscle.

In your particular case, I would strongly recommend a lift (mastopexy) in addition to an augmentation.  From your photos, the position of your nipple and areola sits a bit low on the surface of your breast.  This would be called ptosis (or droop) and the best way to measure this is in relation to the inframammary fold, which is where the breast meets the chest.  Your nipple sits 1-2 cm below your fold. This is unlikely to be addressed with a breast augmentation alone.  Placing an implant in a subglandular plane in a patient who has a larger, ptotic breast will likely worsen the situation.  Placing the implant behind muscle will put you at risk for having your breast tissue fall off the surface of the implant, which would not be aesthetically pleasing.

Finalizing your decision with a surgeon that you feel comfortable with is essential. Good luck.

I received conflicting suggestions from three plastic surgeons about breast surgery...

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Thank you for the question. It is extremely common to receive different opinions from different plastic surgeons about the best way to proceed after surgery. Each plastic surgeon may have his/her opinion that is based on their specific/unique education, experience, and personal preferences. Their opinions may also be shaped by unfavorable results they have encountered in their practices. It is quite amazing how adamant each plastic surgeon can be about the superiority of his/her recommendations…

In my practice (not to confuse things for you even more), I would not offer you a breast augmentation procedure, without breast lifting at the same time.  I do not think that you will be pleased with the long-term outcome of the breast augmentation surgery performed alone.

There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”. The vast majority of breast implants placed in the "sub muscular" position are really being placed in the "dual plane" position ( partially sub muscular, partially sub glandular).

I think it is in the best interests of most patients seeking breast augmentation surgery to have implants placed in the “dual plane” or sub muscular position. This positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability of the implants (which may increase with time, weight loss, and/or post-pregnancy changes).
The submuscular positioning also tends to interfere with mammography less so than breast implants in the sub glandular position. The incidence of breast implant encapsulation (capsular contraction) is also decreased with implants placed in the sub muscular position.
On the other hand, sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants seen with flexion of the pectoralis major muscle) they can be seen with breast implants placed in the sub muscular position.
I hope this, and the attached link, helps. Best wishes.

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.