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).

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.

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