I am so confused I may just cancel surgery! Over or under?

The doctors at my chosen practice almost exclusively do over the muscle with silicone. They feel they get great results. But every article on the web says they are fake looking, dangerous and a bad idea. I would rather not cut my muscle and don't want the distortion when I move. But I have thin skin, being 45 years old. But a decent amount of breast tissue...a small B. This is making me very stressed and that is not what I wanted from this experience. Help! Thanks!!!

Doctor Answers 13

Over Or Under The Muscle?

Thank you for your question!  I preform mostly under the muscle breast augmentations.  Under the muscle is a lot more of a natural look.  Due to your anxiety I would recommend you go get a second opinion.  Best of luck!
Dr Dhaval PatelDouble Board CertifiedPlastic SurgeonChicagoHoffman Estates Oak Brook


Hoffman Estates Plastic Surgeon
4.8 out of 5 stars 79 reviews

Above or Below the Muscle

I perform breast augmentation placing implants above as well as below the muscle.  The key is to have enough native breast tissue to adequately cover the breast implant for the subglandular position.  The advantage of no dynamic motion deformity is significant.  Having said that, another important factor is the size of the implant.

Without at least photos, no recommendation here.  I would see an experienced board certified plastic who performs both of these procedures and review the pro's and con's of your specific situation.  Don't worry about the canned answers on line where surgeons always before an operation the same way no matter the patient.   Best of luck.

Ronald A. Lohner, MD
Philadelphia Plastic Surgeon
4.7 out of 5 stars 20 reviews

Submuscular

There are many advantages to sub muscular dual plane placement and very many disadvantages to sub glandular placement. I would see no indication to do anything but sub muscular. This can be best accomplished with the armpit approach. The most sophisticated approach to breast augmentation is through the armpit with a surgical camera (transaxillary endoscopic). Using this modern approach the space can be crafted under direct vision, with virtually no bleeding and no postoperative bruising. Most importantly, the shape of the breast is meticulously created. The other, older methods of insertion are technologically less advanced. Both silicone and saline implants can be placed through the armpit by a surgeon with skill and experience using this approach. The incision in the crease is the oldest method of placing the implants and puts a scar directly on the breast.

Subglandular silicone implant placement is the historical approach to this surgery, and was widely used in the 1960's. The implant edges are more visible, the risk of rippling is higher, the implant is in contact with the non-sterile breast tissue so the risk of infection and capsular contracture is higher. The interface between the breast tissue and the muscle is blurred so the implant interferes with mammography more than sub muscular placement. The blood supply surrounding the implant is worse so the risk of capsular contracture is higher. The support for the implant is less so there is more long term shape abnormalities and sagging. The look of a sub glandular implant is much less appealing than a sub muscular implant. The placement of sub glandular implants makes any subsequent revision surgeries more complicated and less successful. There are no advantages to sub glandular implant placement.


I am so confused I may just cancel surgery! Over or under?

First, because of your anxiety you need a second opinion.

Beautiful results can be achieved with either technique ans capsular contraction even on top of muscle is much less with modern day implants.

Most important is that you have adequate breast tissue to cover and hide the implant. Next is the skill of your surgeon.

Don't fret just have a good long heart to heart with your surgeon

There are pros and cons to everything we do in plastic surgery.  Pocket position is no different. In general both can provide excellent results and the best option depends on your individual situation.  I do quite like to go over the muscle and potentially under the fascia if possible.  If need be for too large an implant for the thickness of tissue then I go below.  

This is where a good conversation is so important.  Have a heart to heart with your surgeon.  If they aren't willing to ahead of time then you have to wonder what will happen if you have any problems after.  Discuss the exact concerns you just listed with your surgeon and see what they say.  If you think that they are really listening and helping you choose the right pocket then stay with them.  If you think that you are a number in an assembly line... move along.  

Everyone has an opinion.  There is no perfect answer, just the most right one for you when you consider all the information available.

Rodger Shortt, FRCSC
Toronto Plastic Surgeon
5.0 out of 5 stars 52 reviews

Breast Implant Position

There is a lot of "negative press" out there about breast implants placed above the muscle. I believe this is because most surgeons do not know how to do them well or were trained to put them below the muscle and just never learned how to do them well above. I have been placing all types of breast implants above the muscle for over 30 years and get excellent, very natural results that not even their family doctor can detect frequently. If the surgeon you have seen gets excellent results and those results you are shown are what you would like to achieve, then trust them. It is not the skin that makes the implant palpable, it is the covering breast tissue, which you say you have "a decent amount of." Although you can use smooth implants in this position, I prefer textured ones as I think it gives one more defense against scar contracture. 

Robert T. Buchanan, MD
Highlands Plastic Surgeon
5.0 out of 5 stars 5 reviews

I am so confused I may just cancel.

A little nervous is OK, but anxiety is a sign that things are not set and not an experience any of us want. There are many options in breast augmentation, none right or wrong, though you can try discussing what you have learned with your chosen practice, but remember that augmentation is elective and if you are uncomfortable a second opinion might be the best for you.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.1 out of 5 stars 40 reviews

I'm confused - I may just cancel my surgery!

Thank you for your question.

I'm sorry to hear that you're so frustrated by your experience so far - breast augmentation should be an exciting journey, not one fraught with worry.

Having said that, it's perfectly normal to have some anxiety and possibly even "cold feet."  Surgery is no small matter - I tell my patients that it's normal to be a little nervous, and that if they're not a little nervous, then I am.  I say that because, as you know, there is always some risk involved, and the nervousness is a reflection of the fact that you understand that the procedure is not risk-free.  

With regards specifically to your question about over- vs under-the-muscle, if you ask 100 plastic surgeons about their preferences, you'll likely get 200 answers.  This is because different surgeons have different concerns and approaches to their patients, depending on their experience, training, and the patient's concerns, anatomy, and goals.  Many patients get wonderful results with subglandular / over-the-muscle placement.  While it's somewhat simplistic to think that one size fits all (you don't buy underwear that way, do you?), it is reasonable to expect that certain surgeons can get reliable, predictable results with a particular approach.  Remember that this may be due, at least in part, to patient selection.  If a particular surgeon is only willing to do breast augmentation on patients who are good candidates for a particular approach, then it would be expected that the majority of the breast augmentations done in that practice would be done with that approach.  Another way to think of it - if the head coach of your baseball time is only willing to recruit left-handed pitchers, then you would expect that all the coach would say that his team gets great results with left-handed pitchers.

Ultimately, you should discuss these concerns in detail with your plastic surgeon - ask specifically why your surgeon thinks that subglandular placement is the best option for you (it might be).  You deserve to be comfortable with the surgical plan to achieve your goals, as well as the surgeon you've chosen to execute that plan.

Best wishes.

Breast augmentation over or under

Many surgeons have many more opinions about whether above or below the muscle is better. I  have a customized approach to each patient and discuss with them the benefits and risk of either position of the implant. To discuss over the muscle versus under the muscle we need to first start out with discussing how implants were originally placed in and the drawbacks of the original placement of implants had. When breast implant surgery was first begun implants were placed exclusively over the muscle . These implants were rather rudimentary and had problems with leakage capsular contraction as well as visibility rippling and other problems that were much more common in the past. For this reason many surgeons had a knee-jerk response to place almost all of their implants under the muscle.  This leads to less capsular contraction and less visibility and rippling in the upper two thirds of the implant in the area that the pectoral muscle is covering on the patients right breast this would be from about 10 o'clock to about 4 o'clock on the circle.  God did not mean for there to be a breast mount underneath the muscle so this can sometimes lead to some distortion especially when a woman is flexing her pectoral muscle. If you look at woman working out at the g , if their breasts move up when they exercise, they are subpectoral implants . It's also a bad idea to place implants in a sub pectoral pocket if the patient has a widely spaced pectoral insertion or a funnel shaped chest. This leads to poor outcomes . it's also a little bit more difficult  to get a very sharply defined a breast without putting high profile implants when you place them in a sub pectoral pocket but all in all the advantages often out right way the risk with sub pectoral placement. Recently there've been the development of what is called dual plane placement. Most of us were already doing this in our practice but now it is been officially described as adual plane. The dual plane Relieves some of the drawbacks of subpectoral placement in patients with a very lateral pectoral insertion. and can get past the drawbacks of it Dual plane can also gives some of the benefit of a subglandular implants "look" with out having the drawbacks of the sub-glandular  implants capsular contraction. All and all a good well-rounded experienced board-certified plastic surgeon should be able to discuss with you their likelihood of achieving your desired goals. I would trust your surgeon over anything you read on the Internet. 

Oliver P. Simmons, MD, FACS
Columbia Plastic Surgeon
5.0 out of 5 stars 9 reviews

Confused and cancel surgery

I am sorry that this is causing you anxiety.  It sounds like the best thing you can do right now are as follows.

1.  Talk to your surgeon again.  Ask him/her if this is truly the BEST OPTION for you.  Explain your concerns.  A good PS should be able to explain to you why one approach is BEST for you and not just the way they do the majority of their patient's surgery.

2.  Have a consultation with another board certified plastic surgeon in your area. 

3.  Stop reading the internet!  LOL  Make sure that you are reading information from reputable sources and not just anecdotal information put out there on message boards. 

This surgery is 100% elective.  While a little anxiety is normal, if you aren't ready, reschedule, gather your thoughts and have at a later date.

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.