Breast augmentation - do I need a lift? Would over or under the muscle be best? (Photos)

Dear 4n457451A,

determining whether you need simply a breast augmentation versus a breast lift can be somewhat complicated. It depends on a number of factors including skin laxity and current nipple position. Generally speaking, if the nipples are lower than the inframammary line the patient will most likely need a breast lift. If the nipples are at or above the inframammary line we can generally get by with just a breast augmentation depending on the size of the implant the patient wants. I often still using implant when I perform a breast lift because it provides more upper breast fullness after the lift. To be sure a consultation with a board-certified plastic surgeon will help determine what the patient actually needs.


Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Hello, for people with some degree of breast sagging, the decision whether to have a lift comes down to many factors, such as tolerance of the extra scars, expectations of the result (are you ok with lower breasts that are larger, or do you want them lifted higher), costs, additional risks of the breast lift, the surgeon's advice, etc. As for breast implants pockets, they have unique advantages and disadvantages. Implants inserted in front of the muscle tend to drop faster and fill out the lower breast, but there is not as much tissue coverage. Implants placed under the muscle have more coverage, but they might sit too high on the chest, leaving the lower breast looking loose and unfilled. A compromise of the two pockets called the "dual plane" pocket is also an option, but it also has unique risks (like "windowshading", in which the muscle moves abnormally when contracted). I realize this is just a general discussion of options, because specific advice can only be provided during a thorough in-person consult. The consultation process involves deterring the patient's overall health and their cosmetic goals, then doing a proper breast exam including detailed measurements to check the degree of sagging and asymmetry. Next, I explain the different operations and their risks, before showing examples of the different outcomes on my photo gallery. I hope your procedure goes well.

Your concern is very understandable, many people hope for a simple augmentation but find out a lift might be recommended, which can affect both cost and decision-making.

Your nipples are located below your breast fold and since the implants are centred behind the nipples, they would sit low on your chest and not offer any fullness in the upper pole. For this reason, a lift would be recommended.

Thanks for your question! Without a doubt, you need a breast lift to get a good result. Implants, without a lift, would look droopy and mispositioned. It appears as though you are very thin in the upper chest, so I think subpectoral would give you the most natural look. Best of luck!

You are a poor candidate for breast augmentation. You have a large skin envelope, your breasts are widely separated and you have no cleavage. You would benefit from a breast lift using The Bellesoma Method. This will reshape your breast tissue creating upper pole fullness without implants, elevate them higher on the chest wall and more medial to increase your cleavage. Vertical scars are avoided, nipple sensation (in 95%) and the ability to breast feed are maintained. Later, fat transfers or small implants can be placed if additional volume is desired.

Best Wishes,

Gary Horndeski, M.D.

Thank you for your question. I have been in practice for over 30 years and breast surgery and revision breast surgery is a large portion of my practice. Unfortunately, when implants are placed on top of the muscle, the skin will just stretch without anything between the implant and the skin envelope. I have a whole gallery of problems associated with implants on top of the muscle. The good news is that you can have attractive breasts. You just need to have the implants placed under the muscle and a breast lift. Breast lifting is an art form that many plastic surgeons have not mastered. You should be able to have a beautiful result. Best wishes to you.

A lift with augmentation would give best results. Implants would be under the muscle.

Unfortunately, in my experience, Implants only, even above muscle, will still leave lower poles very low.

Further consultations and discussions with your/plastic surgeons is recommended until you are comfortable.

Patient concerns regarding the appearance of their breasts can typically be divided in two pools: volume, ptosis (droop). The procedures to address these issues are as different as the issues themselves. However, these concerns are not mutually exclusive. Many patients, whether they are aware or not, will benefit from both.
There are two factors which can help to answer the question of which surgery will deliver the most satisfying result: mastopexy, augmentation or both. Patients must first consider the position of the NAC (nipple areolar complex i.e. the pigmented portion of the breast) as it relates to the inframammary crease. If the nipples are at or below the level of the crease the patient may benefit from a lift or mastopexy. The breast lift is designed to elevate sagging breasts to a more youthful position. It also helps to reshape and tighten the skin of the breasts. This is typically accomplished via a periareolar (around the nipple) incision with or without a vertical incision.
Mastopexy is an effective way to address sagging breast, however, the changes which accompany weight loss or pregnancy can also decrease volume of the breasts. When a woman wants the volume restored, or increased, a breast augmentation will also be needed in conjunction with mastopexy. Augmentation can help restore the volume loss which is well known to women following children. There are a number of options available to women considering augmentation ranging from size and implant type to access incision.
A breast augmentation alone may also be appropriate if ptosis is mild. If the patient is comfortable with the natural appearance of the breasts but desires them to be larger, a breast augmentation alone is the right procedure. Augmenting significantly ptotic or sagging breasts tends to magnify the problem. In these cases, a mastopexy performed in conjunction with an augmentation is preferred.

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 faster when compared to subpectoral augmentation.
• 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 (“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.
Based on your photos, you are a reasonable candidate for dual plane augmentation. It is difficult to assess the need for a lift without an exam. You appear to be a borderline candidate. It is possible to stage the 2 procedures.
There is a procedure for every problem. To determine which technique is right for you, consult with a board certified plastic surgeon Patient should discuss their concerns with their physicians in order to make an educated decision.

Thank you for your question. Consideration for breast lift is based on several factors, including "droopiness" of the breasts, position of the nipple-areolar complex in relation to the inframammary fold, and desire for "uplifted" results. Based on the photographs, your skin appears to be quite thin, and going under the muscle may be more helpful for a more natural look and better protection for the implant. Otherwise, the risk is that the implants will fall and only fill out the portion of the breasts. A discussion with board-certified plastic surgeon will help guide you toward the results you desire. Good luck on your journey!