Over or Under with a Lift? (photo)

I am 35 year old mother of two breast fed infants left with with saggy size B breasts. I keep reading that UNDER the muscle is a better choice but my surgeon has recommended a breast lift with over the muscle implants. WHY?

Doctor Answers 10

Ask your surgeon

You should ask them why they recommended this. Sometimes, implants placed over the muscle can give the breasts a bit more of a lift, but usually this is done when a breast lift (mastopexy) is not performed. Ask your surgeon if this is an option for you: allergan inspira Triform 2 implants with a high profile placed over the muscle.

Toronto Plastic Surgeon
5.0 out of 5 stars 176 reviews

Breast Lift With Implant Under Muscle Possible

Thank you for your question. Most plastic surgeons today prefer to place breast implants beneath the chest muscle to provide better coverage of the implant, easier mammogram examination, and possibly less saging or chance of capsular contraction with time.

After pregnancy the breast atrophies, loses volume, and sags and from your photographs it appears that you have significant sagging or ptosis although an examination in person is required for accuracy.

In patients with significant breast sag or ptosis a breast lift must be done if the breast implant is to be placed beneath the chest muscle in most cases. Both breast lift and breast augmentation can be done at the same operation however many surgeons prefer to do the breast implant first, allow the implant to settle, and after 3-6 months the breast lift can be done to more accurately position the nipple and areola over the implant in an optimal location.

In some cases, if you are luckey, the implant will settle into the breast and a lift may not be necessary after 3-6 months.

For patients who do not want a breast lift, many surgeons prefer to place the implant over the muscle beneath the breast gland to allow the implant to settle lower into the breast and avoid a lift..

Both procedures will work in most cases however I think most surgeons today would prefer sub-muscular breast augmentation and dermal mastopexy or breast lift. However the choices yours as long as you are fully infrmed and understand the difference and long term indications. The link below explains this more clearly.

Be sure to consult a plastic surgeons who are certified by the American Board of Plastic Surgery, are experienced in cosmetic breast surgery, and have an excellent reputation in your community

Thanks for providing your photograph.

Really difficult to tell without examining you how much tissue coverage you have for an implant above the muscle.  But from the photo alone it looks like you would be a candidate for dual plane under the muscle and you won't need a breast lift.  It is to your advantage to avoid a breast lift if you don't really need it; less visible scars and fewer overall complications when the breast is being enlarged in the same operation.  

Leila Kasrai, MD, FRCSC
Toronto Plastic Surgeon
5.0 out of 5 stars 66 reviews

Your surgeon's preference

is the most likely reason why over the muscle was recommended.  With dual plane techniques, the theoretical 'advantages' of lifting more with on top of the muscle no longer exist.  When I compare my dual plane techniques with another surgeon in town who goes above the muscle, I know my result have better long term results... and that is what the word on the street is.  So it really comes down to your surgeons preference.  Otherwise going under the muscle give you more fullness on top, prevents rippling on top, better mammograms where implant is under muscle and the biggest reason, less risk for contractures under the muscle... but the breasts move with chest muscle contraction.

Curtis Wong, MD
Redding Plastic Surgeon
4.8 out of 5 stars 33 reviews

Breast Implants with a Lift: Under or Over the Muscle?

Mothers may find that pregnancy and breastfeeding contribute to loss of volume and firmness. To perk up a drooping breast, your surgeon will remove excess skin, reposition the nipple, and redrape and tighten the remaining skin to support the breast. The areola may also be reduced in size. A mastopexy (breast lift) raises droopy breasts from one to several inches and excess skin is removed. If you're sagging or asymmetrical, and are looking for perkiness, you'll need a lift--or, if you also want more volume, a lift and implants.
If you want the most natural-looking breast you'll need a subpectoral implant, in which the implant is placed under the muscle. This procedure diminishes the incidence of capsular contracture, the formation of hard scar tissue around the implant which occurs in 10 to 30 percent of cases. Subpectoral implants aren't right for everyone, though. If you have saggy breasts, and implant placed under the muscle won't fill out that empty breast sack, and you'll get what we call the "double bubble" look, where the implant is situated next to your armpit and the breast hangs several inches below it.

It is now possible with the newest technique for you to enlarge your breasts without resorting to implants! Specially prepared fat taken from another part of the body, such as the stomach or hips, is placed under the breast tissue to provide increased breast size without the need for artificial implants. The technique is called autologous fat transfers and autologous simply means "your own." And who doesn't have a little fat to spare?

In short, you must know -- realistically -- what you are starting with, as well as what you want to look like when surgery is done. Do you want a natural appearance or a round, perky look? These are some of the factors I weigh with my patients when evaluating what type of procedure to do.

Michelle Copeland, MD, DMD
New York Plastic Surgeon
4.6 out of 5 stars 10 reviews

Implants with concurrent mastopexy should be placed below the muscle

In my opinion breast implants placed at the same time as a mastopexy should be placed below the muscle. This has nothing to do with aesthetics but rather  preserving adequate blood supply to the nipple areolar complex to prevent vascular damage.

Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon
4.7 out of 5 stars 35 reviews

Under or over with lift

  My recommendation is under    the muscle ,   for  many   reasons  that   others  had  already   explained .

Your  personal conditions  :  skin   , mamary    gland    tissue ,  and  position of your   nipple areola complex  the  more  logical option    is under    the muscle     ,an  implant over  the  muscle  will be    great   ate    the first    3 months    but  then   the   action  of   the  implant   to  this skin   and poor   mamary tissue  wil  end  up , in   a saggy    breast    with eventual palpation   of   implant .  it  is much  easier for  a plastic   surgeon to place  an implant over  muscle   but  in  long terms   will not  be  the  best  decision.

Cynthia Disla, MD
Dominican Republic Plastic Surgeon
4.4 out of 5 stars 88 reviews

Lift with implants and pocket location

I prefer in most cases to place the implants under the muscle especially in women that have very thin soft tissue coverage.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Under muscle better

Based on your picture and apparent skin laxity my preference is a dual plane sub muscular implant placement. The results last longer and look better in my opinion. You may benefit from another consultation with a board certified plastic surgeon.

Gregory T. Lynam, MD
Richmond Plastic Surgeon
4.9 out of 5 stars 59 reviews

Over or Under Pectoralis Major Muscle with a Lift?

Thank you for the question and picture. I would strongly recommend that you choose the sub pectoral ( dual plane) positioning of breast implants for many reasons. I cannot speculate as to why your plastic surgeon is recommending otherwise.

I will try to outline some of the differences here;  you may find the attached link helpful as well.
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 these sub muscular position.

 Again, in your case, given the lack of significant soft tissue coverage, I would suggest the sub muscular ( dual plane) positioning.

 Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,488 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.