Would I need a lift for OTM implants? Is UTM a better option if I don't want a lift? (Photos)

Question

I am considering implants however after research, I feel like over the muscle has more benefits and would give me the look I want at a smaller size. Looking at my images, would I need a lift for OTM? Would UTM be a better option for me if I needed a lift and didn't want one?

Christine Fisher, MD, FACS · Answer

Thank you for your thoughtful question. I commend you for taking the time to carefully research breast augmentation procedures in order to determine the approach that will best help you achieve your aesthetic goals.

When evaluating whether a breast lift is necessary in addition to augmentation, we consider several important anatomical factors, including the position of the nipple relative to the inframammary fold, the degree of breast ptosis and skin laxity, overall skin quality, your desired implant size, and the amount of upper pole fullness you hope to achieve. In some patients, augmentation alone can provide sufficient improvement, while others may benefit from the addition of a mastopexy to achieve a more balanced and long-lasting result.

Based on your photos, your nipple position appears to remain well above the inframammary fold, which suggests that you may be an excellent candidate for augmentation alone without the need for a formal lift. In appropriately selected patients, careful implant selection can often restore fullness and improve breast shape while maintaining a natural appearance and avoiding the additional scars associated with mastopexy surgery.

That said, these decisions are highly individualized and are best confirmed during a comprehensive in-person consultation and examination, as photographs alone cannot fully assess tissue characteristics, skin elasticity, or breast asymmetries.

With regard to implant plane selection, I perform the majority of my augmentations in a subfascial plane with a modified micro dual-plane technique that selectively elevates a small cuff of pectoralis muscle along the upper pole. In properly selected patients, this approach can provide a very natural upper pole transition and soft tissue coverage while minimizing some of the animation deformity that may be seen with more traditional dual-plane augmentation techniques. As with all aspects of breast surgery, the optimal implant plane should ultimately be individualized based on your anatomy, tissue characteristics, lifestyle, and aesthetic goals.

I would encourage you to seek evaluation with an experienced board-certified plastic surgeon who can perform a detailed examination and discuss the surgical plan best suited to your anatomy and desired outcome.

Best wishes as you continue your research and decision-making process.

Semih Yildiz, MD, FEPOBRAS · Answer

In my experience, implant position should not be used as a way to avoid a lift if the nipple and skin envelope already need tightening. Your photos suggest a borderline situation, but the key measurement is where the nipple sits compared with the breast fold and how much lower-pole skin laxity is present.
Over-the-muscle implants can give a softer upper shape in selected patients, but they do not raise the nipple and can make sagging or a waterfall look more noticeable over time. Under-the-muscle placement may help coverage, but it also does not replace a lift. An in-person exam is needed to choose safely.

Daniel Barrett, MD · Answer

Dear Fearless120549,

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

Ted Eisenberg, DO, FACOS, FAACS · Answer

Under the muscle is the best option and no lift is needed. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Oliver Chang, MD · Answer

Based off your photos - your breast are in good position in relation your chest anatomy (limited on photos and angles) but ideally your breast will be in the same position as they are now but fuller if the breast augmentation is done properly for either OTM or UTM. 
Advantages for OTM - no animation, no pec chest weakness; but slight increase chance for capsular contracture and / or implant rippling / show. 
Advantages for UTM - less chance of implant show especially at the superior aspect, less chance for capsular contracture. 
Discuss these things with your surgeon and ask questions. And ask about needing a lift - based off your photos, ideally a lift is not needed. Hope this helps.

Kadir Berat Oyur, MD · Answer

Based on what you’re describing and the general appearance in your photos, over-the-muscle (OTM) can absolutely give a softer, more natural slope at smaller sizes but it also depends heavily on your existing tissue and skin quality. If there’s even mild sagging (nipple sitting low or breast tissue falling off the implant), placing an implant alone whether OTM or under the muscle (UTM) won’t correct that, and you may still need a lift to achieve a balanced, youthful shape. Trying to “avoid” a lift when it’s indicated usually leads to a result that looks bottom-heavy or unfinished. UTM tends to give more upper pole support and can sometimes mask mild laxity, but it won’t truly replace a lift either. The decision isn’t really OTM vs UTM first&mdash;it’s whether your anatomy requires repositioning of the breast (lift) to get the result you have in mind. A proper in-person assessment (measuring nipple position, skin elasticity, and tissue thickness) is key before choosing the plane, otherwise you risk compromising the final aesthetic.

Jacob Carlson, MD · Answer

In your case, either option will yield very nice results. You don't have any breast ptosis, so do any sort of a lift would simply be done to move the areola position a small amount. Your surgeon should be able to create a great result with placing the implant either on top of or under the muscle.

Jeffrey M. Darrow, MD · Answer

Thank you for your photos. Your nipple/areola and all of your breast tissue is positioned above the fold underneath your breasts.  This is the aesthetically correct position.   Whether you place your implant over the muscle or under the muscle, you will end up with an enhanced version of your current breasts and therefore, there is no reason to have a breast lift.  A lift would not benefit you and would place unnecessary incisions on your breast. Discuss this in detail with your plastic surgeon. Best wishes.

Brian K. Reedy, MD · Answer

Thanks for your question! I think you would be a great candidate for OTM with Motiva's implants if you don't get too greedy with size. You definitely do not need a lift. I would suggest finding a board-certified plastic surgeon in your area to achieve optimal results. Good luck!

Donovan Rosas, MD · Answer

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 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.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other.

Based on your photos, you do not appear to need a lift. The NAC appears to be sitting well above the fold.

As always, your board certified plastic surgeon can help guide you in your decision making process.

Would I need a lift for OTM implants? Is UTM a better option if I don't want a lift? (Photos)

Answers (12)

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