Are subglandular or submuscular breast implants perkier? Which will "stay up" longer? I have a fear of sagging.

Question

I am a female in her twenties with good breast tissue (full B cup). I really like the perky, full on top, "held in" look. My first consultation recommended that I go with the subglandular position due to my breast tissue but I am worried about the "ball in sock" sag effect over time. I like how subpectoral implants look but I haven't found many "after" photos of subglandular. I also own a pole fitness studio so the shorter recovery associated with subglandular is appealing. Please help me!!

Larry S. Nichter, MD, MS, FACS · Answer

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

Austin Hayes, MD · Answer

It's a great question. I strongly prefer under the muscle implants because the muscle provides another layer of camouflage for your implants. The muscle contours the top of the implant to give it a more natural slope and hide rippling of the implant. Implants under the muscle have a decreased risk of scar tissue forming around the implant (capsular contracture).  Also, breast cancer screening with mammography gives better images of breast tissue when implants are placed under the muscle. Although an implant on top of the muscle can be a good choice for some women, for very thin women there is not enough camouflage for the implant to look natural. When considering breast augmentation make sure you find a board certified plastic surgeon who will take the time to answer all of your questions and explain all of your options, so that you can decide if breast augmentation is right for you.

Nelson Castillo, MD · Answer

Thank you for your questions.  In my opinion most women are better candidates for implants placed in a sub muscular position. This is a result of the typical quality and amount of breast tissue women seeking implants present with in my office.  Sub muscular implants minimize the risks entailed with breast augmentation, such as capsular contracture, rippling, and palpability while looking more natural over time, and make mammography easier.

Keith Hodge, MD · Answer

I prefer the subpectoral position (behind the muscle). There are several advantages to this. One, you will avoid the "ball in sock" appearance. Secondly, you will have more natural appearing cleavage. Thirdly, you will have a decreased risk of developing a capsular contracture. This is the development of too much scar tissue forming around the implant which may cause the implant to feel firm. Fourthly, you will have a better mammogram when you are older. If you are young with good breast tissue, I would not place your implant in the subglandular plane for those reasons. Hope this helps!

Brian Coan, MD, FACS · Answer

Thanks for your detailed question about breast augmentation.  In our office we perform numerous breast augmentation surgeries with the standard silicone gel implants, the anatomically shaped implant (aka the gummy bear implant) and even saline implants.  More often than not, patients who sound like you (who are also in good health and physically fit) tend to prefer the anatomically shaped implant placed submuscularly.  The very small amount of time you may be able to "save" with having the procedure performed subglandularly is minimal and the procedure will last you many years so I strongly urge you to do what's best for you aesthetically in the long run.  Additionally, I would encourage you to have an "implant try on session."  This is an exclusive service our office offers our breast implant patients.  Additionally, since we offer the "rapid recovery" breast augmentation, many of our patients have the procedure on a Friday and may be back to work on the following Monday (however exercise is restriced for several weeks after surgery for all breast augmentation patients).  Any board certified plastic surgeon (who is also a member of the ASPS -- American Society of Plastic Surgeons) will have similar restrictive protocols for exercise after surgery.  Whatever you decide we wish you all the best in your aesthetic journey.

Steven Wallach, MD · Answer

In general, I prefer to place them in the submuscular pocket in the majority of patients to provide more soft tissue coverage in the upper pole. I do not think one position will sag more than the other.

Tom J. Pousti, MD · Answer

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) they can be seen with breast implants placed in the sub muscular position. 
Best wishes.

Robert T. Buchanan, MD (retired) · Answer

In most people, there is no difference in the postoperative perkiness of the breasts between sub glandular or sub muscular breast implant placement. If there is droop already, I prefer sub glandular placement as it allows easier positioning of the breast during the lift. Additionally, in someone who uses her arms as you must, I would never consider placing implants sub muscularly. Although, neither placement should lead to a "rock in a sock" look, in you, sub muscular placement is much more likely to displace. Because of my population with most women very active, most of my breast augmentations are sub glandular. All those on PlasticSurgeryToday.com are sub glandular. (Patient  54501 needed a lift but declined.)

Are subglandular or submuscular breast implants perkier? Which will "stay up" longer? I have a fear of sagging.

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