Under or above muscle? (photos)

I am 42, breastfed 2 kids, considering breast augmentation silicone anatomic shape. I am slim, active in sports like running, cycling, swimming, skiing. Had consultations with 3 different recommended surgeons, and scheduled operation with one. But they say different things which make me uneasy. The surgeon I have scheduled operation with definately advise under the muscle. One says I can choose but recommend above muscle due to a bit "hang". The third says above muscle to avoid "double bubble".

Doctor Answers 8

Over/Under...The Debate Rages on

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 sub muscular placement (for a number of reasons) there are distinct differences to each approach. Based upon these patient and surgeon can decide together which approach is best suited for you.

 

Subglandular Augmentation:

       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 sub pectoral augmentation (because no muscle work).

 

·      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:

 ·      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. This may or may not be an issue of concern to a particular patient but they should be aware of it before making their decision.

 

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.


Westchester Plastic Surgeon
5.0 out of 5 stars 7 reviews

Under or above muscle

Submuscular placement may be more uncomfortable the first few days following surgery. The possible benefits of submuscular placement are that it may result in less palpable implants, less capsular contracture, and it will make it easier to image the breast with mammography. The appearance may be more “natural” for patients who are very thin. Subglandular placement may make your surgery andrecovery shorter and you may have less discomfort. This placement may provide a slight “lift”. Subglandular placement may result in more palpable implants, more capsular contracture and more difficult imaging of the breast with mammography. This placement is often recommended for those patients with sagging, but do not want a breast lift (mastopexy) and for tubular breast deformity

Under the muscle

I assume you want a good, long-term result, right? If so, go under the muscle.  Yes, you may need a little lift someday, but that's better than having your breasts hanging on your abdomen!  Good luck.

Robert S. Houser, DO
Columbus Plastic Surgeon
5.0 out of 5 stars 15 reviews

Under or above muscle

You have to first understand that under the muscle means that only part of the implant will be covered by muscle. That is why it is actually called a dual plane positioning. In your case, with using an anatomical implant, you can fill in the lower breast skin, have some, possibly 30-40% of the implant below muscle and achieve a natural appearance.  You need to be aware that an anatomical implant will not give you as much fullness in the upper part of your new breast mound though as the majority of the implant will fill in the lower with much less in the upper pole

Julio Garcia, MD
Las Vegas Plastic Surgeon
4.8 out of 5 stars 26 reviews

Placement Options

Hello,


There is some logic to each of the recommendations because of your anatomy. Your nipples are in a low position with what appears to be a short space underneath- minimal space in the lower poles of your breasts. That means that an overly large implant or surgical lowering of your fold could put you at risk of double bubble. Thin upper breast/chest tissues mean a sub-mammary implant could be easier to see and feel, but under the muscle is less able to fluff out and give a lifted look to sagging breasts. Careful discussion of your goals and expectations is key. 

The plastic surgeon you are most comfortable with whose plan best matches your needs will be a good choice. Be sure that you seek a board certified Plastic Surgeon who specializes in this area.


All the best 

Breast augmentation: under or above muscle?

Thank you for the question. There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”.    I will try to outline some of the differences here;  you may find the attached link helpful as well.


 

I think it is in the best interests of most patients seeking breast augmentation surgery to have implants placed in the “dual plane” or sub muscular position.  This positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look  of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability  of the implants (which may increase with time, weight loss, and/or post-pregnancy changes). The submuscular positioning  also tends to interfere with mammography less so than breast implants in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position. 



On the other hand,  sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants  seen with flexion of the  pectoralis major muscle)  that can be seen with breast implants placed in these sub muscular position.    Best wishes.

Breast Implants/Breast Augmentation/Anatomic Gummy Bear Implants/ Silicone Implants/Breast Implant Revision Surgery

I appreciate your question.

The best way to determine implant size is based on chest wall measurements that fit your body.  Once we determine that we can choose the profile based on what you want or need to achieve.  

Implants under the muscle, there is less risk of capsular contracture.  Anatomic implants tend to give a more natural shape with more nipple projection.

The best way to assess and give true advice would be an in-person exam.  Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.

Best of luck!

Dr. Schwartz

Board Certified Plastic Surgeon

#RealSelf100Surgeon

#RealSelfCORESurgeon


Different Recommendations

You will find that different surgeons have different recommendations for patients.  Usually this is based on the surgeon's training and personal preferences.  All three surgeons come recommended and likely would produce good results for you.  You appear to be thin and under the muscle does make some sense.  Going above your muscle will provide some advantages too.  I'd recommend reviewing each surgeon's before and after galleries and then evaluating the overall experience you and in each of their offices.  Pick the surgeon that you liked the best that has a staff that was attentive.  You will interact with the office staff a fair amount as well and they can make a difference in your overall experience.  Best wishes!

Levi J. Young, MD
Overland Park Plastic Surgeon
5.0 out of 5 stars 44 reviews

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.