Would I benefit more from over muscle or under muscle? (Photo)

Question

42yo 5’3” 122# 34B. Used to have an athletic build (now I m a softy). But still have pronounced pectoral muscles and a double bouble of dense breast tissue. Looking for a C cup again with Upper Pole slightly curved or natural slope. Want something that will age gracefully with me. One doc suggested subglandular, another submuscular. Placement and shape suggestions?

Daniel Barrett, MD · Answer

Dear Peaceful440372,
I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

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.

Zeshaan Maan, MD · Answer

Based on your images, you have more than enough breast tissue to avoid a sub-muscular plane for your breast implants. Sub-muscular implants increase post-operative discomfort due to the dissection of muscle, and they also carry a risk of animation deformity. The advantage of submuscular for you would be a reduced risk of capsular contracture, but you can also achieve this by placing implants under the fascia of the muscle rather than under the muscle. 
An experienced plastic surgeon will work with you to select the technique best suited to you.

Gianfranco Frojo, MD · Answer

There is overwhelming high level evidence that a submuscular position (dual plane pocket) has the least amount of potential future problems in breast augmentation. I would recommend finding a board-eligible or board-certified plastic surgeon with aesthetic surgery fellowship training (a total of 7 years of plastic surgery training). In addition, it helps to have a 3D simulation to see what the potential results are.

Camille Cash, MD · Answer

Most of the breast augmentations I perform are under the muscle.  The benefits include a more natural look, a lower occurrence of capsular contracture, and it disguises the upper portion of the implant.  Based on your stated goals it seems submuscular would work well for you.

Connie Hiers, MD, FACS · Answer

I prefer placing the implants behind the muscle for better upper breast fullness, hiding the implant edge, and some support to the weight of the implant. Measurements are needed to see if a lift if needed. Two photos do not show sagging, but two photos do.

Would I benefit more from over muscle or under muscle? (Photo)

Answers (6)

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