Lift with 450cc - Over or under the muscle? (photo)

Over the muscle (subglandular) pocket is very commonly used around the world and has a possibly easier recovery as there is no muscle involvement and there is no implant animation or movement with the muscle flexing. There is less soft tissue coverage and more defined upper pole especially with a high profile implant. There may be some efficacy in using a textured implant when going above the muscle. Its not a bad choice, but may have a higher capsular contracture rate. Make sure you get a good lift as this is the deal breaker for your result, not the implant.

Dear Reader,In my practice, I prefer to place the implants below the muscle.  I believe is looks better, make the implants less palpable and has lower risk of capsular contracture.  I would advise you to have this conversation with your surgeon prior to surgery for sure.  Good luck and be safe.Respectfully, John T. Nguyen, MD, FACS, FICSDouble Board Certified Plastic SurgeonAmerican Board of Plastic SurgeryAmerican Board of Surgery

I feel that under the muscle is almost always a better operation.  The upper pole looks better, there is a lower rate of capsular contracture, and they are held in better...they don't end up as a "rock in a sock'.  Also it is a lot easier to get symmastia with over the muscle.I hope that helps!

Thanks for your question and the photo. Without an exam and measurements it is hard to say exactly what I'd recommend. Combining a lift and an implant is a tricky operation and has a high revision rate and can end up being very expensive. Most surgeons would not use a HP implant with a lift. Placing an implant that is that large (450CC) definitely will put a lot of stress on your lift. I would not place the implant above the muscle. You will have higher incidence of contracture and risk of nipple devascularization above the muscle. Best of Luck!

Hello and thank you for your question. There are several advantages
and disadvantages to over vs under the muscle.  Under the muscle has the
advantage of lower capsular contracture rates, less risk of rippling, and
better visualization with future mammograms.  Most patients say that under
the muscle also has a more natural look and feel.  The size, shape,
and profile 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.   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.  
Best wishes and good luck.
Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Thanks for providing pictures. The decision to place an implant over or under the muscle is related to tissue coverage. The majority of new patients in my office declare they want their implants under the muscle...when I ask them why they tell me because that's what they read and that's what all their friends have. Not a good reason at all for a surgical decision. The other side of that is, with all due respect, I wouldn't recommend calling your surgeon to 'tell' him or her you want them over the muscle. Better to open a discussion about your tissue coverage and what the plan is...if plans for under the muscle now, why not over the muscle. I am a big fan of implants over the muscle when all other parameters come together. Studies have shown over the years that implants under the muscle have a slightly lower capsular contracture rate than over the muscle. Changes in implant design and intraoperative steps can help reduce this risk. The biggest downside of under the muscle is the potential for animation deformity with pectoral flexion. Ask your surgeon about this. Regarding your desired volume combined with a lift, be aware these are opposing procedures: implants make the breast bigger, a lift makes the breast envelope tighter. Put a lot of thought into your desired implant size, ask questions as you are doing. Good luck!

The cleavage desire can be tricky.  You will likely have to employ bras to give you that effect, especially with a high profile implant, depending on your base diameter.  I recommend below the muscle as this does not typically interfere with breast surveillance.

You have more skin excess on the left than the right in your picture.  I start with your exam and photos.  I use 3D imaging for each augmentation patient to evaluate different sizes, above and below the muscle, for you to better understand your appearance after surgery.  After that we can discuss the lift options.  You idea will vary based on what you see in the 3D options.  Would be happy to help you!

If you don't want them to look natural then above the muscle is a bit better. I prefer below the muscle because it gives a natural slope in the upper pole. To have the best cleavage make sure to have the proper diameter of the implant.
All the best,
Talmage Raine MD

Combining a lift with placement of an implant has increased complication risks associated with it.  Placement of a large implant in a suprapectoral position with a mastopexy is associated with even higher risks in my opinion.  My recommendation would be to use a smaller partial subpectoral implant at the time of your mastopexy although some others would suggest separating the procedures.  I feel that the latter guarantees you the need for a second surgery or is most patients who combine the procedures get by without need for revision.  Each surgeon will have their own opinion based on personal experience.  Do not overestimate the value of a high profile implant and what it can accomplish.  Best wishes,Jon A Perlman M.D., FACSDiplomate, American Board of Plastic SurgeryMember, American Society for Aesthetic Plastic Surgery (ASAPS)ABC-TV Extreme Makeover SurgeonBeverly Hills, CaliforniaIG: jonperlmanmd