Over Muscle with Lift...why Not Under? (photo)

I am 35 year old mother of two breast fed infants left with with saggy size B breasts. I keep reading that UNDER the muscle is a better choice but my surgeon has recommended over the muscle with mastopexy. WHY? I trust him but everything I'm reading indicates better results with under the muscle.

Doctor Answers 9

Retro-pectoral to reduce sagginess

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Your photograph shows you have ptotic breasts.  More importantly than the implant is a simultaneous lift.  There is a new technique called Breast Augmentation with Mini Ultimate Breast Lift.  Using only a circumareola incision it is possible to reshape your breast tissue creating upper pole fullness, elevate them higher on the chest wall and more medial to increase your cleavage.  Through the same incision, implants can be placed.  Aligning the areola, breast tissue and implant over the bony prominence of the chest wall maximizes anterior projection with a minimal size implant.  Small silicone gel implants placed retro-pectoral look and feel more natural, are more stable, less likely to ripple or have complications needing revision.  Implants placed in front of the muscle have no support, will descend and sag even more.    


Best Wishes,


Gary Horndeski, M.D.

Texas Plastic Surgeon
4.6 out of 5 stars 230 reviews

Breast Implants

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I can't explain your PS's reasoning.  There are pros and cons to every choice.  I suspect they feel that going over the muscle will fill out the breast envelope.  I would be worried about nipple devascularization with a significant lift at the same time as the augment if going over the muscle.  You should discuss your concerns with your surgeon and consider getting a second opinion from a board certified plastic surgeon in your area.

Asif Pirani, MD, FRCS(C)
Toronto Plastic Surgeon
5.0 out of 5 stars 35 reviews

Implant Over/Under Muscle with Breast Lift

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There are arguments that can be made either way and what your plastic surgeon tells you should make sense to you. I prefer under the muscle with a breast lift. Loose or saggy breast skin in most cases means that the quality of the breast skin and tissue is not strong enough to support the weight of an implant and you may end up with the same problem: a sagging breast (only with an implant inside of it). The muscle provides better structural support for the weight of an implant

Joseph Fata, MD
Indianapolis Plastic Surgeon
5.0 out of 5 stars 105 reviews

Over Muscle with Lift...why Not Under? (photo)

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Not sure why so best to ask in detail the reason. In my hands I recommend "unders" with full lifting operation. 

Submuscular implant placement with mastopexy

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I would agree with you, and would prefer a submuscular placement of the implant along with a breast lift.  An implant over the muscle would tend to leave the implant more exposed and thin out the overlying skin.  

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Over Muscle with Lift...why Not Under?

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I prefer under the muscle when I combine it with a breast lift. I like the way the muscle fills in the superior part of the breast and also covers the upper 1/2 of the implant. There is no right or wrong answer.

With silicone gel implants no great difference placing the implants above or below the muscle.

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Saline implants all things being equal are less likely to show contour irregularities placed below the muscle. Silicone gel implants really make no difference. At the time of a mastopexy when a breast augmentation is done concurrently I always put the implants under the muscle because of the risk of devascularized in the nipple and areola complex.

Over versus under the chest muscle

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Some doctors like placing implants above the chest muscle because that is where the breast tissue is and, therefore, that is where the implant should theoretically look and behave more like breast tissue.  The downside is that there is a greater likelihood of feeling the implants when they are above the chest muscle and there is a higher risk of capsular contractures forming when implants are above the muscle.  I think most doctors prefer placing implants under the muscle, especially when they are doing a concurrent breast lift operation.  I guess that the only way you will discover why your doctor wants to do it this way would be to ask him.

Edwin C. Pound, III, MD
Atlanta Plastic Surgeon
4.6 out of 5 stars 26 reviews

Over or Under the Muscle?

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Good question. There is not any "right" answer. A lot of it depends on what your goals are regarding size vs tightness. Also under the muscle means different things to different surgeons. The Dual Plane technique is a way to place the upper 2/3s of the implant beneath the muscle (getting the advantage of less capsule contracture and a slightly less round look) and the lower 1/3 beneath just the breast (where it can fill out the breast more directly. presumably you have chosen your surgeon after discussing all the issues and after seeing photos of results that you like. Trust your intuition and try not to second guess or micr-manage. Good luck.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.