Patient w/ large breast. Is it better to go over or under muscle? What size on already large breast to keep it natural? (Photo)

I've always had large breast (34dd/36d) but life has lead to weight gain & nursing 2 children caused the fullness to disappear & look like a C. met with 2 Dr.'s one says 350cc & above muscle. The other dr said to bring in photos & they would go under. I have thin skin & don't want to have wrinkling when I lean over but also fear the double bubble if I go under. I hear go bigger but I'm larger already Iarge should I be more conservative? I don't want to look fatter all over with large breast.

Doctor Answers 17

Above or Below Muscle or better yet Dual plane

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In general the benefits of submuscular placement are: Better superior (upper) coverage/hiding the implant in your cleavage where you will show them off the most Much lower rates of capsular contracture or scar tissue build up around the implant Most importantly, implants under the muscle do not interfere with your mammogram. I do not believe there to be any lasting benefit of subglandular (or sub fascial) placement. If your breasts are entirely below the muscle I would recommend a mastopexy (lift), not subglandular placement, to take advantage of the benefits mentioned above regarding submuscular implants. Submuscular implants look better, feel softer for longer and don’t interfere with mammograms, giving you the best chance at early breast cancer detection and highest cure rate should it develop. However, it’s not always that simple. Many times the bottom edge of the pectoralis major muscle ends higher than your natural breast crease. If you place the implant completely under the muscle it “rides high” and delivers a less than ideal aesthetic result, with your natural breast “falling off” the front of the implant. Therefore, to prevent that, I frequently utilize a dual plane placement. This means as much of the upper portion of the implant is under the muscle, for all the reasons listed above, but a small portion of the implant “peeks” out from under the muscle so the implant is nearly centered under the nipple. There are different degrees of dual plane release (I, II, III) but I will do as little a release as possible to achieve an optimal aesthetic result, thereby leaving maximum muscle coverage. During your consult I discuss implant placement options, and during the exam he will determine where you pectoralis major muscle ends compared to your breast fold to estimate the level of dual plane release required to optimize your breast appearance. Best of luck.

Might need more than just an implant...

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What you've lost is the fullness in the upper pole of your breast.  A modest sized implant )in the 350-400cc range depending on the measurements of your chest) will replace that fullness, but you will still have some droop on your upper abdomen.  A lift will help that and also take a little volume away, leaving you a full D cup.  Certainly put the implant UNDER the muscle -- over is only a short-term fix.  Get another opionion and ask about the lift option.  Good luck!

Robert S. Houser, DO
Columbus Plastic Surgeon
5.0 out of 5 stars 17 reviews

Over or under the muscle with my breast implants?

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You are a reasonable candidate for either technique - one of the main reasons to go under the muscle is in patients with a small amount of breast tissue. A 350cc implant will likely provide you a good improvement in volume without being 'too big' but unfortunately there is some subjectivity involved and you must trust that your plastic surgeon understands your goals well. 

Good luck! 

Bryan Correa, MD
Houston Plastic Surgeon

Breast Lift with implants

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Hello dear, thanks for the provided pictures. I recommend you a breast lift with silicone implants under the muscle.

Tania Medina de Garcia, MD
Dominican Republic Plastic Surgeon
4.6 out of 5 stars 441 reviews

Patient w/ large breast. Is it better to go over or under muscle? What size on already large breast to keep it natural? (Photo)

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There are several advantages to going under the muscle. Better coverage of the implant superiorly and medially, less risk of rippling and wrinkling, less risk of capsular contracture and a better mammogram in the future. I also think going behind the muscle allows your tissues to hold the implant in the proper position. You will need a large implant to properly fill out your natural breasts, so going in front of the muscle could lead to a breast lift soon after the augmentation. Best of luck!

Prefer under

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I prefer implants under the muscle as it provides more soft tissue coverage. A lift might be in order as well. Good luck.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Over or under with lift

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Its my belief that implants placed on top of the muscle will put undue weight onto the lifted breast and make it sag again. Implants with lifts are better placed partially under the muscle so as to augment the upper pole of the breast. The breast tissue is then moved upward to line up with the implant with the lift procedure. Vertical tension seems to create a pleasing shape that retains its lift for many years. Smaller implants with more skin reductions has a longer lasting lifting effect than larger implants and small skin reductions. Good Luck!

Marc J. Salzman, MD, FACS
Louisville Plastic Surgeon
4.7 out of 5 stars 58 reviews

Is it better to go over or under muscle? What size on already large breast to keep it natural?

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The answer is easy. Both above and below the muscle implants will give you good results because of your anatomy. Other patients the answer would be different. As far as size, your consult that recommended 350cc would be a modest increase and you don't need a lot. I like implants under the muscle not because of their appearance but because you are  less likely to get a capsular contracture  and mammograms are more easily read under the muscle. You should do fine, good luck. 

Robert Graper, MD
Charlotte Plastic Surgeon
4.4 out of 5 stars 27 reviews

Dual plane vs. over the muscle

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Most likely we'd recommend to place your implants underneath the pectoralis major muscle. The muscle covers the top half of the implant, providing additional thickness of coverage over the implant in the critical cleavage area. This makes it less likely that the implant edges or ripples will be visible when wearing a bra or bathing suit. Studies have also shown that the rate of capsular contracture is lower when the implants are placed under the muscle.

You’ll find that our surgeons usually prefer to place the implant behind the pectoral muscle to give you the most natural look possible. Covering the implant with muscle allows the chest wall to slope naturally and gracefully. This effect avoids an artificial look, even for those patients desiring large implants. Occasionally the surgeons will recommend placing the implant on top of the muscle. I'd recommend being really clear with your surgeon about the look you hope to achieve. Showing him or her photos of your desired breasts can be really helpful in making the right decision during your consultation.

Large breasted woman, what is my best option

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It depends on what you are trying to achieve as a result of surgery. You can see that there are differing opinions among plastic surgeons. My thoughts are that any implant above the muscle allows the weight of the implant to exert more stress on your breast tissues leading to a saggy breast in short time. A sub muscular implant provides better upper breast coverage and support as well as a decreased incidence of capsular contracture and I feel a more natural result. The possibility of a double bubble needs to be addressed and depending on you exam by either what is referred to as a dual plane release or more often a breast lift. Please see a board-certified plastic surgeon and come to a decision best for you. 

I hope this helps

Dr. Edwards

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.