Grade 1 ptosis. I do not want a lift, would over or under the muscle be best? (Photos)

Question

Hello. I have had a few consultations. I just want to get more opinions. I have grade one ptosis. Do not want to get a lift. I’m going with 380-400 cc. I don’t want the fake fake look but I would like a more natural look but trying see what would make up for the sagging more.

Harry T. Haramis, MD, FACS · Answer

Many similar patients avoid a formal breast lift by placing slightly larger implants either totally above the muscle or half under or dual plane.

Gel implants will give a more natural look vs saline which tend to be very full on top or more fake.

Dual plane has advantages of more “lift” of sagging breast, support for implant at fold and less capsule contracture.

Totally above muscle gives most “lift” with more natural look, risks implant descending over time, slightly higher capsule and easier recovery.

Either way, your breasts will stay low, natural. Size range you mentioned is agreeable.

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation (“overs”):

•	Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster 
when compared to subpectoral augmentation.

•	Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).

•	Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.

•	Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.

Subpectoral Augmentation (“unders”):

•	Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.

•	Subpectoral implants have a lower rate of capsular contracture.

•	Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.

•	The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other.  As always, your board certified plastic surgeon can help guide you in your decision making process.

Zoran Potparic, MD · Answer

You seem to be a borderline case for a breast lift. There is nothing wrong with your decision to do augmentation only; if needed, you can do a breast lift any time later. Good luck.

Luis A. Mejia, MD · Answer

Hello, thank you for the question, after evaluating your case... with only augmentation is not sure that they will be perky... having that clear you can choose a natural look or a perky one with a lift.

Kadir Berat Oyur, MD · Answer

Thank you for your question.
Based on what you’ve shared, a combination of breast implants and a breast lift may be recommended to address both volume loss and sagging. Implants help restore fullness, while a lift reshapes and repositions the breast tissue for a more youthful contour.
A consultation would be the best way to determine the most appropriate approach for your individual anatomy and goals.

Mehmet Ozdemir, MD · Answer

Thank you for your question.
Based on the information you provided, breast implants and a breast lift may be recommended to address both volume and sagging. Implants help restore fullness, while a lift repositions the breast tissue for a more youthful shape.
A consultation would help determine the most suitable approach based on your anatomy and goals.

Finny George, MD · Answer

Hi, thank you for sharing your question. Your choice of implants and implant pocket are very personal. Both have their own benefits and drawbacks. A fake look results when you have a very large implant and not enough soft tissue over the implant. Discuss these with your board certified plastic surgeon.

Camille Cash, MD · Answer

Both approaches have pros and cons.  Over the muscle has the main benefit of a little quicker recovery as the muscle isn't involved.  However the weight of the implants is solely supported by an already sagging breast tissue.  Under the muscle has a lower capsular contracture rate, may give some camouflage in the upper pole of the breast, and gives a little more natural look.  Neither approach is designed to lift the breast.  I encourage you to visit with board certified plastic surgeons near you to determine what is best for you.

Ayhan Isik Erdal, MD, FACS, FEBOPRAS · Answer

For your breasts, augmentation alone without a lift would be sufficient. 400cc is a suitable option for you. Looking at the photos, I would recommend Under the Muscle, but a video or examination is needed for a definitive decision.

Grade 1 ptosis. I do not want a lift, would over or under the muscle be best? (Photos)

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