Submusular vs subglandular: Which placement stands the test of time, especially if you plan to breastfeed in the future? (photo)

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, a sub-muscular approach will likely provide the greatest longevity with regards to result.
As always, discuss your concerns with your board certified plastic surgeon (ABPS).

I recommend placing the implant behind the muscle.  The implant selection should be based on a combination of your desired size, soft tissue dynamics, breast base diameter and skin elasticity.  I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with.   Finally, make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery (ABPS), a member of the American Society of Plastic Surgery (ASPS), a member of the American Society of Aesthetic Plastic Surgery (ASAPS), and a fellow of the American College of Surgeons (FACS).Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach TrainedDouble Board-Certified, Double Fellowship-Trained Beverly Hills Plastic Surgeon

Breast augmentation is often performed increase the size of the breast for aesthetic reasons. The implants are most often placed under the pectorals muscle (sub muscular), partially under the muscle (dual plane), or over the pectoris muscle (sub glandular). In a bra, your "wish pics" can be achieved with any of the techniques. Breast feeding is possible with any of the implant positions. 
Advantages to sub muscular implants include a lower risk of capsular contracture, lower chance of rippling, better coverage in thin women, and perhaps a more natural upper pole contour. Implants placed under the muscle can, however, be influenced by the contraction of the pectorals muscle – especially in very athletic women.

Completely sub muscular augmentations are rare as the space available for inserting an implant is small. Often the bottom edge of the muscle is cut and the implants are only partially covered by the muscle. This preserves a smooth transition in the upper pole but allows for a larger implant. This is referred to as dual plane. 

Implants placed over the muscle, in contrast, are more visible. This can manifest as a larger looking augmentation and a sharper transition between the natural breast and the edges of the implant resulting in a more done look. Additionally, in thin women, the folding of the implant in the sub glandular pocket can manifest as rippling of the skin. 
The longevity of the result is based on the size of the implants and the quality of the native breast tissue. Small implants in young, high quality tissue resist gravity longer.See the link below for more information.A detailed examination will help delineate the best surgical treatment. In office sizing and digital three-dimensional simulations can help guide your implant choices. Consultation with a plastic surgeon certified by the American Board of Plastic Surgery would be the next best step.

Thank you for your question. There are pros and cons to both placements and really comes down to personal preference.Implants placed over the muscle have a
more rounded look, which some women feel looks less natural, however
women may prefer this look; it’s a matter of personal preference. Pros
for going over muscle include less post-operative discomfort due to the
muscle staying intact and lower recovery time. For patients with slight
sagging caused by excess skin or laxity, but not enough for a breast
lift, over the muscle may fill out the breast more as because the
implants lie closer to the skin. Cons include higher susceptibility to
rippling as there is less tissue covering the implant and the skin is
receptive to future stretch marks as the implants are only supported by
skin. There is also a higher rate of capsule contracture, which is scar
tissue that can form around the implant causing the breasts to harden.
If the patient has a breast lift in the future or concurrent with the
augmentation, there is also a slightly higher risk with regard to
maintaining blood flow to the nipple.
Below the muscle, submuscular placement
provides more coverage of the implant resulting in less rippling and
palpability of the implants. With this placement pros include, less
chance of getting capsular contracture and there is better mammogram
detection. With the dual-plane technique, implants are covered by both
the breast tissue and the pectoralis muscle, creating a more natural
look. Cons include a slightly longer recovery time due to post-operative
pain and comfort and breasts may appear to sit a bit high until the
muscle fully relaxes.For the majority of my patients, I recommend under the muscle placement with silicone implants for a more natural look, with a lower risk of complications. One of the few situations where I recommend going over the muscle, is if the patient is a body builder and competing in a lot of shows where the pectoralis muscle is flexed. In that case, the muscle is very active and one gets a lot of animation with the implant. For either placement, there are circumstances based on a patient’s anatomy that one may be more beneficial than the other so it is important to be examined by a plastic surgeon to make an informed decision.

In general, augmentations done under the muscle (dual plane) have a lower complication rate than over the muscle and tend to hold up better over time.

Good afternoon!For sure those goal looks can be created by going under the muscle- and will last longer, look better, feel better, encapsulate less, and give higher quality mammograms (get the feeling I'm a little partial to unders? haha). Nipple sensation and breastfeeding should be no different over vs under.I have attached a link to my XL Breast Augmentation photo gallery for your review- almost 100% of them are under the muscle and many are exactly the look you like- hope it helps!

Thank you for the question and photos. This is a very important question that you can’t get a clear and definite answer to because there isn’t one. The placement of the implant depends on each individual person’s breast anatomy, goals, lifestyle, needs and expectations. Each placement has its pros and cons. It is possible to achieve your wish look with either placement. Ideally you should be seen in consultation to discuss your goals with the surgeon who has experience with both placements and together you can choose the right implant for you. During your consultation you can see photos of both placements. Best of luck!Dr. Khuthaila 

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.  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.
Harvard-trained plastic surgeon

Breast feeding will not be affected in my experience by the location of the implant.  Submuscular implants in general tend to hold up a little better, but many sub glandular implants will also be just fine, so plastic surgeons still use them in some situations.  Be sure to discuss your goals and concerns with your board certified plastic surgeon and consider the pros and the cons. Be certain your surgeon is properly certified.  I've attached a link where you can start your search. 

For most women, the configuration of their breasts will determine the best placement.  For women with minimal breast tissue and small perky breasts, sub-muscular placement is usually the best.  That placement will result in high "perky breasts", that will slowly soften over time.  However if the woman has any significant breast tissue ( more than and A cup) and the implant is placed sub-muscularly, as she ages ( even in a few years) the implant will say fixed under the muscle, but the breast tissue will begin to droop downward due to gravity, and develop a "double bubble " deformity, with a bulge  of the implant above and the drooped breast belowIn a sub-glandular placement in a woman with some breast tissue (A to small B cup or greater), both the breast tissue ( which is attached to the back of the muscle) will descend together resulting in a natural looking breast.In short, the desired size, the type of breast desired, the longevity,and the patients aesthetic desires for their breasts, will determine the type of placement.
You can see examples of the different placements on my Real Self photo page.