Over/Under Muscle or Dual-Plane? (photo)

hello thank you for your question and provided information as well..based on the photo shown I see that you are a good candidate for a breast augmentation  muscle dual plane ..my recommendation is that you go to consult in person with a certified plastic surgeon who sees you and determine the amount of cc you need to get good results.

Thanks for the photos and sorry fat grafting didn't work out. You are a candidate for a breast augmentation using a dual plane technique which offer benefits over placing the implant on top of the muscle.  The actual details of your implant size, profile, and placement can only come after a careful exam and detailed discussion with your surgeon though. Best wishes and keep us posted !

Hello and thank you for your question. You are a great candidate
for a breast augmentation using a dual plane technique.  The size, profile, and shape of the
implant is based on your desired breast size/shape, your chest wall
measurements, and soft tissue quality.  This decision should
be based on a detailed discussion with equal input from both you
and your surgeon.  This entire surgery
can be performed with a small incision technique.  Make sure you
specifically look at before and after pictures of real patients who have
had this surgery performed by your surgeon and evaluate their results.   The most important aspect is to find a
surgeon you are comfortable with. I recommend that you seek consultation with a
qualified board-certified plastic surgeon who can evaluate you in person.
Best wishes and good luck.
Richard G. Reish, M.D. FACS
Harvard-trained plastic surgeon

Thanks for your question and the photo. Without an exam, it is hard to tell exactly where the nipple position is relative to the fold. IMO there is no reason to put the implant above the muscle. Simply too many downsides to that. I do think that most would use a dual plane technique. You have an asymmetry it appears in the nipple height that will likely be made more apparent when the implant is placed. I would address this with your surgeon. Find a Board Certified Plastic Surgeon in your area that is an ASAPS member and specializes in cosmetic breast surgery. Best of Luck!

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 fasterSubglandular 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 when compared to subpectoral augmentation.Subglandular implants can also create the illusion of improved cleavage by preferential over-dissection of the central/medial pocket allowing the implants to be forced more to the midline. There is no limiting muscle as there is in a submuscular augmentation. 
Subpectoral Augmentation/Sub-muscular (“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.With regards to your specific question, in my practice, the vast majority of patients undergo a submuscular augmentation +/- a lift//mastopexy as needed (to avoid a snoopy deformity). Based upon your photos, you would likely benefit from a lift in conjunction with your augmentation. 
As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Hi. In my experience under the pectoral muscle placement is the best, it  not only avoids implant migration or displacement, but also will give you a very natural look. Over the muscle placement  will make your breast droop  within a year.
Dominican Board Certified Plastic and Reconstructive Surgeon
International Member of the American Society of Plastic Surgeons (ASPS)
Member of the International Society of Aesthetic Plastic Surgery (ISAPS)

From your photograph, you appear to be a good candidate for breast augmentation.   Under the muscle positioning is beneficial for multiple reasons including better implant overage, better scar tissue development and contour.  It is initially more painful and takes longer to heal.   Only rarely does the implant settle too much because of muscle contraction and this is usually managed with activity restrictions.  The snoopy deformity is a different concern and is more relevant for patients that have tubular breasts before surgery, which you do not.  Over the muscle (subglandular) approaches are associated with a more obvious appearance of the implant and increased scar tissue not "weighing down" breasts.  I am not a fan of dual plane approaches.  I hope that is helps

Hi, Sarah. Thank you for sharing your photos and for your question. Reviewing your pics, you appear to be a good candidate for breast augmentation. There a number of pluses and negatives between over- and under- the muscle placement. Many surgeons today actually de facto perform a "dual-plane" technique when placing implants sub-muscularly, and therefore consider the terms synonymous. (With early "sub-muscular" techniques, the pectoralis muscle may not have been released or an attempt may have been made to cover the entire implant with muscle using the pectoralis, serratus, and rectus muscles.)A well-trained, experienced plastic surgeon will be able to make the most advantageous recommendations after an in-person exam and consultation. I would suspect that overall you would benefit from placement of the implants in the dual plane (sub-muscular). Your tissues, especially in the upper pole, appear somewhat thin -- placing the implant below the muscle would give a smoother, more blended contour in this area, as well as being more supported. In addition, the risk of capsular contracture and visible rippling is lower. In addition to plane placement, the implant type (saline vs. silicone), as well as the size, shape, and profile of the chosen implant will each have an important bearing on your results. Best of luck to you, should you decide to proceed with breast augmentation. And I hope you achieve excellent results and have a speedy, uneventful recovery. Dr. Ghafoori

Hi - That must be  very disappointing not to get the results that you were hoping with fat transfer.  I see patients from other practices that are in the same situation as yourself.  At this point an implant  sounds like it would be the best choice for you.  Based on the picture you provided I would recommend a dual plane technique.  There are obviously pros and cons of all approaches, which, is what your consult is for - to discuss these.  By all means definitely avoid the snoopy appearance.  It is not a good look.    Some patient's implant can settle enough that things can look relatively okay but in my opinion it isn't worth the risk.  It looks like your skin is really good quality and that you have breast tissue to cover your implant well so I think you will have a really pretty result.  Good luck on  your aesthetic journey!
All the best - Dr. Bekanich

Thank you for your question. Based on the picture dual plane breast aug may give optimal results. Multiple factors involved in deciding the size and placement of implants. Please consult with a board certified PS for evaluation and to discuss your goals.