Once over the Muscle. Can I Now Go Under Muscle?

Question

If I choose to redo my implants (d cup saline over the muscle TUBA) to silicone, under the muscle same size...will I have issues with look? In other words is going from over to under a problem?

Jason Hess, MD · Answer

As you may know, the submuscular approach is generally the preferred placement of implants. When compared to a subglandular pocket, these submuscular implants are associated with a more natural appearance, a lower incidence of capsular contracture, and less palpability (you can feel the implants less). There are a few options in this scenario. One is to remove the implants and allow the breasts to heal back down to the muscle. After 4-6 months, the implants can be replaced in a submuscular plane. Most patients understandably prefer to avoid a staged procedure. In order to remover the implants, an incision in the periareolar region or inframammary fold is required. Silicone implants can then be placed in the submuscular plane. However, this creates two breast pockets. To maintain the implant in the submuscular plane, a dermal matrix implant such as AlloDerm or surgimend may be required. This is sutured on the lower aspect of the muscle and over the implant to maintain the implant in the submuscular plane. This can be accomplished with a good aesthetic outcome and no overlying skin issues. Hope this helps.

Otto Joseph Placik, MD · Answer

Going from over the muscle to under the muscle is a feasible option but this may require sutureing the muscle to the tissue to prevent the implant from "popping" back into the previous pocket. It also would require a scar on the breast.

Hayley Brown, MD, FACS · Answer

If you have D sized implants on top of the muscle, and you take the same volume and go under the muscle, you could have issues with the overlying skin. In an over the muscle situation, the implant is within the breast itself and fills it up. The under the muscle pocket is high and the implant sits along the ribs and pushes forward. If there is any redundant skin or sagging, the skin may not be filled out properly, and could be loose or sagging above and beyond the level of the implant. And no, you would not be happy with that look. Sometimes in that situation the skin needs to be tightened in the form of a lift. Your plastic surgeon will tell you if you are a good candidate for a pocket site change, and whether or not you would require any type skin tightening procedure.

Tom J. Pousti, MD · Answer

Thank you for the question.

	In the event of capsular  contracture or severe breast implant rippling replacing implants in the sub muscle position is the best way to go in my opinion.  This may or may not be possible depending on your specific situation.

	Generally, it is possible to replace implants under the pectoralis muscle (dual plane).  However, the major issue of concern is the overlying breast tissue and skin and whether further surgery will be necessary to achieve the aesthetic  results desired.  For example, some patients who have implants replaced into the sub pectoral space may benefit from breast lifting to achieve the desired goals.

	This type of surgery does require some level of experience. It would behoove you to seek consultation with well experienced board-certified plastic surgeons well-versed in revisionary breast surgery.

	I hope this helps.

Steven Wallach, MD · Answer

Changing the breast implant pocket form overs to under the muscle is done all the time.  It should be fine.

Michael A. Jazayeri, MD · Answer

You can definitely change the location of your implant placement. I am glad you are choosing a sub-muscular location as it has several advantages. First, the rate of capsular contracture is lower. Second, and most importantly, it will interfere less with mammography.

Peter A. Aldea, MD · Answer

Regarding:  "Once over the Muscle. Can I Now Go Under Muscle?
	If I choose to redo my implants (d cup saline over the muscle TUBA) to silicone, under the muscle same size...will I have issues with look? In other words is going from over to under a problem?"

	We regularly switch implant position from OVER the muscle to under the muscle and from under the muscle to a new pocket under the muscle.

	While no breast implant position is perfectly ideal and free of compromises, the under the muscle position has a lot more advantages than the over the muscle position both in the short and long term. However, depending on the width of your chest wall, it is questionable that every very large implant can be as easily accommodated in the under the muscle position as it could be in the over the muscle / under the breast gland position. That has to be determined on a case by case basis.

	In summary, in general going from OVER to UNDER is NO problem.

	Dr. Peter Aldea

Robert N. Young, MD, FACS (retired) · Answer

In my opinion it is difficult to go under the muscle once the breast tissue is seperated from the muscle.  You may get better results to just put the Silicone above the muscle.

William F. DeLuca Jr, MD (retired) · Answer

That is certainly not an uncommon request. Subgladular placement of saline prosthesis over time usually resulted in visible rippling and a palpable prosthesis which is an unwanted long term effect. This has been significantly lessened with the use of a dual plane approach. Switching to a submuscular position is quite common and will give a more natural appearance to the breast and certainly make the prosthesis less palpable. The only issue is the amount of skin present after replacing the prosthesis in the submuscular plane which sometimes needs to be addressed with a lift. Your surgeon at the time of your examination should be able to easily evaluate that possibility.

John Whitt, MD (retired) · Answer

Your implants can certainly be moved from a subglandular to a submuscular position. However, I don't think this can be done with a TUBA procedure (which I do not perform). You would have to accept a scar in a different location.

Once over the Muscle. Can I Now Go Under Muscle?

Answers (10)

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