Can I get away with over the muscle implants 500CC? (Photo)

500 cc implant weight over 1 lb. each and will not be stable long term. Your breasts are widely separated, you have poor cleavage and the nipple-areola complex are low on the chest wall. I would recommend a mini lift. Using a circumareola incision, your breast tissue is reshaped, elevated higher on the chest wall and more medial to increase your cleavage. At the same time, fat transfers or small implants can be placed if additional volume is desired.

Best Wishes,

Gary Horndeski, M.D.

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.

Hello and thank you for your question. Honestly, a formal in-person evaluation would be needed to determine the best treatment. There are several reasons for this:
1) Bra sizes vary based on the clothing store (for example, Victoria's Secret tends to upsize everyone by a whole cup size)
2) Most women do not wear the proper exact fitting bra size for their bodies
3) The exact volume (in cc) needed to change cup size is different for different body types (e.g. 32A to 32D requires a different implant size than 38A to 38D)
4) Be careful NOT to fall into the trap most women do- they see a certain implant size (e.g. 285 cc) or perhaps their friend had a certain size, and they want or request this or another size based on that. Everyone's body is different- 285 cc implants on your friend might look VERY different than they would on you. Be very careful not to make this mistake, because the goal is to find the right size and shape for YOU- for your particular body and your breasts.

Because of those multiple factors, and because it is KEY to fully evaluate your breasts in person to make a full set of precise measurements to select the proper implant for you (incorporating factors like amount of breast tissue, implant type, base width, projection, etc), answering your question really would need a formal personalized consultation- to say anything before that would simply be guessing, which would be both unfair and unhelpful to you.

Your breasts are such a KEY area of your body and your femininity- therefore, you should ONLY trust an experienced aesthetic plastic surgeon. As such an expert, I have had extensive training and experience with complex aesthetic surgeries under a multiple world-renowned experts in the field. I’d recommend for you to setup a formal consultation with me (or another plastic surgeon who is extremely comfortable with aesthetic plastic surgery procedures) for a formal consultation to thoroughly discuss your surgical goals, undergo a formal examination, evaluate all your options (surgical and nonsurgical), and decide on the best procedure(s) and type of anesthesia for your specific case. I hope this helps!

Dr. Donald Groves
Aesthetic Plastic Surgeon

Hello,
I perform under the muscle as well as above the muscle. It would be beneficial to view your wish photos. But, I would recommend above the muscle, under the subfascial lining. You won't have the risk of muscle animation, bottoming out, etc. You will also be able to get closer together and have more cleavage when going on top of the muscle.
All the best,
Dr. Joe

Thank you for your question. Recently the trend is to place implants over the muscle. It prevents animation deformities and your chest muscle pushing your implants downward and laterally. There are advantages to both site placements, and I recommend you visit a Board-Certified Plastic Surgery to discuss your options.

The short answer to your question is that yes, an implant that large can be placed subglandular for you. The downside is that it is much more likely to be visible as an implant with potential rippling as well in that location. Dual plane placement (partially under the muscle and partly under the breast) is a great option that avoids some of the issues with over the muscle implants of such size, especially given you likely have less than 2cm of breast pinch from what i can tell in the photos in the upper medial area. Hope this helps!

Dear CindyRomero,
breast implant type and sizing selection is a complicated process and requires a detailed consultation that includes a discussion of your goals, a detailed examination, and a lengthy discussion. But the decision will always start and end with the patient. When it comes to sizing, we have all of our patients find 3 photos of their desired breast size. We ask for naked breast photos because clothing can obscure the true size (push up bras). Next, we consult with patients and go over the photos and take detailed breast measurements during a physical exam. Next, we using a sizing algorithm to determine a range of implants that will work based on the exam and the measurements.Lastly, during the operation, we use silicone sizers in the operating room to see how the size actually looks in the breast. We sit the patient up in the operating room, while asleep of course, and compare the sizer result with their desired look photos. If it is too small, we start the process over with a slightly larger implant. We don't stop until we get the perfect match.Of all of my breast augmentation patients, every one of them has been happy with their size due to this detailed and meticulous process. You don't want to invest time and money into a result that is either too big or too small.You should discuss your concerns with a board-certified plastic surgeon and make sure that your surgeon understands your goals.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

OTM and UTM are both good options. The main reason the majority of surgeons and patients choose UTM is that the rate of contracture is lower with UTM placement. Make sure you discuss this with your surgeon.

Recovery time when implants are placed in the subpectoral position by a surgeon who is expert in evidence based best practices is virtually the same as over the muscle. Return to all daily activities including driving a car is around 48 to 72 hours, with the exception of exercise, which can resume four weeks. Implant drift to the sides is not due to muscular pressure, but instead curvature of the ribcage, a phenomenon that could potentially affect implants in either plane. Along with an inframammary incision, prospective hemostasis, and the use of an implant delivery funnel, subpectoral implant placement will lower your risk of capsular contracture compared to over the muscle. You should consider a breast lift as well; placement of implants over the muscle will only exacerbate implant drop out and a 'ball in sock' breast appearance for you. Go find another doctor.

Thank you for your question. A large portion of my practice is dedicated to breast surgery and revision breast surgery. You are an excellent candidate for a standard dual plane breast augmentation with silicone implants. I have a whole gallery of patient's I have long-term deformities associated with placing implants on top of the muscle. There is virtually no support when you place the implants on top of the muscle, and they tend to slide down and have a much higher rate of capsular contracture. An animation deformity is possible and probable in every body. The vast majority are happy and the animation deformity is minimal. You should be able to have an excellent result. Best wishes to you.