Healed and Fluffed - what to expect from under muscle results?

Question

So, I am 4'10", 100 lbs, currently a 32 A, probably a AA in one boob. My I am getting a lift (saggy from breastfeeding) and implants. So, because breast tissue will be removed and I am going under the muscle, am I accurate in thinking: Once fully healed, settled, dropped fluffed (etc.) the end result tends to visaully appear smaller? Such as: 285 cc - ends up appearing as a 265 cc 265 cc - ends up appearing as a 245/250 cc

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.

With regards to your specific question, a retro-pectoral augmentation will demonstrate less projection and may appear to be slightly smaller. The degree to which this effect becomes appreciable is hard to predict. That being said, these small differentials in perceived size are subtle and unlikely to make or break a result.

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

Semih Yildiz, MD, FEPOBRAS · Answer

Under-muscle implants often look higher, tighter, and smaller in the early weeks because the muscle and skin envelope are still tight. As swelling improves and the implant settles, the breast usually looks softer and more natural; it does not reliably lose a fixed number of cc, and a 285 cc implant cannot be translated into a predictable visual 265 cc result.
With a lift, some skin and possibly a small amount of tissue are removed, so final fullness depends on your breast width, tissue thickness, implant profile, pocket, and how much lift is needed. For a petite frame, small volume differences such as 20 cc may be hard to see, so choosing by sizers, base width, and desired upper-pole fullness is more useful than trying to convert cc numbers after healing.

Frank Agullo, MD · Answer

Most lifts result in a breast size reduction, so they subtract volume from the overall result. Your surgeon should be able to estimate how much volume reduction you will have from the lift.

#StayBeautiful,

@RealDrWorldWide

Kadir Berat Oyur, MD · Answer

Your intuition is entirely correct, and it is a very common phenomenon for patients to feel that their implants look slightly smaller once they are fully healed, settled, and "fluffed." When an implant is initially placed under the pectoralis major muscle, the tight, unyielding muscle tissue compresses the implant, pushing it upward and making it appear highly projected and firm. Over the first few months, as the muscle relaxes and stretches to accommodate the new volume, the implant drops into its natural position and expands horizontally, which naturally diffuses some of that initial front-facing projection. Additionally, because your surgeon will be performing a concurrent breast lift, they will be removing stretched skin and reshaping your existing tissue into a tighter, more compact brassiere envelope, which can alter your overall visual perception of volume. While a 285 cc implant doesn't physically lose volume, your expectation that it may visually look closer to a 250cc or 265 cc profile once the tissue relaxes is a highly realistic mindset to have going into your procedure.

Mehmet Ozdemir, MD · Answer

You are tracking the process beautifully, and your intuition about how implants settle is spot on. During a lift with implants, the surgeon typically doesn't remove your actual breast tissue; instead, they remove excess skin to tighten the area. Because the implants are placed submuscularly, the tight chest muscle will initially compress them, but as you heal and they "drop and fluff," the muscle relaxes, allowing them to project forward and actually look *fuller* rather than smaller. That being said, on your delicate 4'10" frame, a difference of 20cc to 35cc is just a couple of tablespoons of volume and will look very similar once healed. The illusion of them looking smaller later on is usually just your eyes adjusting as the initial surgical swelling goes down, so leaning toward the 285cc can give you a bit of insurance against that fading fullness without overwhelming your petite proportions.

Healed and Fluffed - what to expect from under muscle results?

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