4'11" athletic build, 110lbs, low body fat. Over or under the muscle? (Pohto)

Question

I went for a consultation for breast implants (255 cc) and the assistant told me I would have to go over the muscle. She said if I wanted to go under the muscle they would have to do a breast lift as well. I am looking for a second opinion. I am 4’ 11 athletic build, 110lbs and low body fat. I am training for a body building competition. Could I still go under the muscle?

Jake Thayer, MD · Answer

Thanks for the question. 
While I cannot speak to your other consultation, a few things come to mind with implant plane choice. Breast augmentation is still commonly performed both below and above the muscle depending on the patient's anatomy and preferences. If you have thinner tissue (ie you are skinny), placing the implant beneath the muscle is a nice way to cover the upper portion of the implant and avoid implant visibility. To the contrary, going under the muscle can increase your risk of "animation deformity" which is when the implant / breasts move abnormally when the pec muscle is flexed. As a body builder, this may be more of a consideration for you given your increased muscle mass. You appear to have minimal ptosis (natural breast hang) and depending upon your aesthetic goals, you may be a candidate for submuscular augmentation alone (without lift). 
I hope this helps!

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

Daniel Barrett, MD · Answer

Dear Epcathletics,
I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Ted Eisenberg, DO, FACOS, FAACS · Answer

After I measure and discuss goals with my patients, we then look at pictures of women (my patients) with similar measurements with different size and style breast implants. They also get to see what they would look like when the breasts have fully dropped and fluffed and in clothes. You get to see actual results and the surgeon's experience and not a virtual idea of what can be achieved. Women tell me that this process is very helpful in determining what size and style breast implant is right for them. Mildly Sagging Breasts: If your breasts are mildly droopy, a saline or silicone gel implant placed behind the pectoral muscle might help create the illusion of perkiness. That’s because as the implant fills out the top of the breast, it also fills out the bottom, making it look as if the nipple has moved higher. It hasn’t. You can always get a lift later if you feel you are not perky enough when fully settled and healed. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Connie Hiers, MD, FACS · Answer

Going over the muscle will be less painful and you will not see the muscle pushing the implant when you flex. However, you will sag more. going behind the muscle will hide the implant better and give better upper breast fullness and support. When you flex, you will have great definition of your muscle. Many body builders like this. You will need to be limited in your weight training initially behind the muscle.

Camille Cash, MD · Answer

Yes from the submitted information you can consider under the muscle implants.  You do not need a breast lift.  Be aware that after surgery you will have lifting restrictions in place so you may want to wait to have surgery until after your competition is over.

Jeffrey K. Scott, MD · Answer

All I can say is that  the previous advice make’s absolutely no sense at all. You will absolutely not need a breast lift. I would  recommend going with breast implants no larger than what you have listed. I would recommend placing the implants in the “dual plane sub muscular pockets” this means the upper aspect of of the implants are covering the pectoralis and the lower aspect of the implants are located below where the muscles exist. If you place implants on top of the muscle only, things may look ok in the early  post operative time frame, but as time goes on there is a significant  probability of the implants showing significant rippling do to over stretch.

Mats Hagstrom, MD (license on probation) · Answer

Most plastic surgeons who have busy breast augmentation practices tend to favor, sub, pectoral, or under the muscle placement of breast implants.
If your nipple is below the inframammory fold then you may be a candidate for having a breast lift.
Based on your pictures, I don’t think a lift is indicated and I don’t think changing the placement of the implant is going to make that much difference.
Placing the implant below, the muscle has a lot of advantages, and is the preferred way of doing the procedure by most plastic surgeons.
I generally recommend all people considering cosmetic surgery have multiple consultations to help find the right provider.
There’s no correct number of consultations needed but patient should recognize that there is significant variation in skill and experience for almost all plastic surgery procedures, depending on the provider selection.
Breast augmentation outcomes are based on three variables.
The first is the patient candidacy for the procedure. The second is the choice of implants in regards to size shape, and type.
The third variable is the surgeons ability to place the implant in the correct and anatomic position.
The discussion of how the implant should be placed should be done by the primary surgeon and preferably not by an assistant.
Perhaps having a few more consultations, wouldn’t be a bad idea.
During each consultation, ask each provider to open up their portfolio and show you their entire collection of before, and after pictures of previous patients, who have similar breast characteristics to your own.
 Bring pictures of your own breast to use as a reference.
And experience provider should have no difficulty showing you the before and after pictures of at least 50 previous patients.
Being shown a handful of pre-selected images, representing only the best results of a providers career is insufficient to get a clear understanding of what average results look like in the hands of each provider.
You should also ask each provider what their most common reason for revision surgery is, what their revision rate is and what the revision policy is.
 we all do revisions.
Finding surgeons were honest about this is an important variable to consider.
Those who claim they never do revisions are probably not offering patients the best possible outcomes.
A 10 to 15% revision rate is probably ideal.
Different providers will also have different ways of guiding patients through implant choices.
Some providers do this better than others.
When in doubt slow down and scheduled more consultations.
Best,
Mats Hagstrom, MD

4'11" athletic build, 110lbs, low body fat. Over or under the muscle? (Pohto)

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