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.

Ellen Ozolins, MD · Answer

Thank you for your question. It is possible to do implants without a lift if you accept that the result will be fuller but not very perky. A 380-400 cc implant can help fill out the loose tissue and improve upper-pole fullness, but it will not truly lift the breast, and if the implant is too large, it can actually make the sagging more noticeable over time. For the most natural look, the implant should be chosen based on your breast width, skin quality, and nipple position, not just cc size, and many patients in your situation do best with a moderate or moderate-plus profile rather than something very projecting. If your goal is natural fullness and you are okay with a slightly softer, lower-set look, augmentation alone may work well; if you want a clearly lifted shape, a lift remains the only way to achieve it. Have an in-person examination with a board-certified surgeon to confirm that augmentation alone will match your goals and to choose the safest implant size and profile for your anatomy.

Muge Sevindik, MD · Answer

You have Grade 1 ptosis. This means your breast tissue is positioned below your nipple. This can be resolved with an augmentation in the subfascial plane using an anatomical implant of a size appropriate for your body proportions. With very large sizes, you will move away from a natural appearance and increase the likelihood of sagging over the years. A smaller anatomical or ergonomic implant will yield a natural and beautiful result.

Ted Eisenberg, DO, FACOS, FAACS · Answer

Do I need a breast lift? You might not need one. After I measure and discuss goals with my patients, we then look at pictures of women (my patients) with similar measurements with different size and style breast implants. They also get to see what they would look like when the breasts have fully dropped and fluffed and in clothes. You get to see actual results and the surgeon's experience and not a virtual idea of what can be achieved. Women tell me that this process is very helpful in determining what size and style breast implant is right for them. Mildly Sagging Breasts: If your breasts are mildly droopy, a saline or silicone gel implant placed behind the pectoral muscle might help create the illusion of perkiness. That’s because as the implant fills out the top of the breast, it also fills out the bottom, making it look as if the nipple has moved higher. It hasn’t. You can always get a lift later if you feel you are not perky enough when fully settled and healed. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Gerald Minniti, MD, FACS · Answer

Get your breast aug and find out the truth: it won't look natural. It will look abnormal: lumps on top (the implant), tissue hanging below. A discordance. A two piece breast. Bigger implants don't help and will only lead you back to the operating room as well. You want sexy breasts. They will be when you do the right thing.

Paul M. Parker, MD, FACS · Answer

Based on your pictures, your soft tissues look relatively thin to me. If they in fact are less than 1.5 cm in thickness when you pinch the upper pole of the breast, dual plane implants would be a better choice to allow for a more natural look. In patients whose soft tissue thickness is less than this amount, subglandular or subfascial placement of implants will often show the edges of the implant. Hope this helps.

Jacob Carlson, MD · Answer

You will get a great result with an augmentation alone, particularly with the size implants you have chosen. I would recommend talking with surgeons about what you are wanting to accomplish in terms of your goal for the augmentation. If you want a more natural, gradual slope to the upper pole of the breast, I would recommend using a less cohesive implant. If you want more upper pole fullness/roundness, I would suggest a more cohesive implant. Based on the pictures you provided, I would guess that you have adequate tissue thickness to have the implants placed on top of the muscle or underneath the muscle. The reason that's important is prevent the implant from being visible/palpable in the upper pole of the breast. With more cohesive implants, you're less likely to see/feel any rippling anyways.
If your surgeon chooses to go 'under the muscle,' I would suggest asking them if they're intending to use the "dual plane" technique. Doing so will allow the implant to settle appropriately. If they're planning to go on top of the muscle, are they going to place the implant in the subfascial plane or the subglandular plane? With ~400cc implants, subfascial might be difficult and may lead to more of a waterfall deformity. With the surgical technique that exist now, placing implants in the subglandular plane isn't as 'forbidden' as we were once all taught.

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.

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

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