Do Subglandular Implants Start Sagging Sooner Than Submuscular?

Question

I don't want my new boobs to sag after a few years. I am getting 375cc silicone subglandular implants. My surgeon says for the look I like this is the best choice and I agree. But does this mean that my breasts will sag sooner because they aren't behind the muscle? I really don't want saggy boobs especially since I am paying so much for them.

Richard H. Tholen, MD, FACS · Answer

Sagging occurs when the skin has fewer elastic fibers, collagen content, and thickness, which is a function of your own genetics. Implant position does not CAUSE sagging, but patients that have sagging to start with are sometimes advised to have submammary implant position to fill-out the loose skin brassiere.

Implants (in either position) do NOT "lift" breasts, but as they drop into position behind the breasts, the implant volume can make the lower pole breast volume greater, giving the appearance of nipple/areola "lift."

To some extent, implant size (weight) also plays some role in the amount and onset of sagging, but submuscular placement minimizes edge "feel," the round (unnatural) "Baywatch look," and in particular, capsular contracture. This position also makes breast self-examination and mammography easier. These reasons are why most plastic surgeons recommend submuscular placement. Since the pectoralis major muscle does not cover the implants completely inferolaterally, beyond the edge of the muscle the implants are below the breasts (or more accurately, the muscular fascia), so this is actually a "dual-plane" position (though this is really only one pocket). Most surgeons who use the mostly-submuscular partially submammary (subfascial) position simply abbreviate this and call it "submuscular."

That is, until some plastic surgeons advertised and marketed "dual-plane breast augmentation" as something "special" when in fact that is what all of us who use this position utilize!

Realize that your implants never sag or droop; that occurs with your skin and own tissues. Anything that helps to support the implants will decrease the rate and severity of sagging, but choosing position as a way of minimizing this is MUCH LESS important than a supportive bra, and accurate surgical pocket creation in the first place. Of course, capsular contracture can "hold" implants in a particular (firm and unnaturally round) position, but our surgical efforts are directed at avoiding bleeding or bacterial contamination, which minimizes capsular contracture.

Since you brought up cost, I would suggest that rather than choosing implant position to try to minimize "saggy boobs," you should choose an experienced ABPS-certified plastic surgeon who will give you the best advice as to the overall results you seek. Re-operation for ANY reason is much more of a cost issue than this single aspect! Another one or two consultations might be in order to ensure the entire operative plan is appropriate.

For examples of my patients with varying degree of breast droop ALL of which had submuscular augmentation, click on the link below and look at cases 6, 11, 13, and particularly 24 and 27. Best wishes! Dr. Tholen

Tom J. Pousti, MD · Answer

Every patient is different with what they need but I think that sub-muscular breast implants provide a nicer, longer lasting result for patients. Because the implants are being held up by the breast skin only for a sub-glandular augmentation, there is more of a chance for the "sag". Please make sure that your surgeon is a board certified plastic surgeon who has experience with breast surgery and is a member of the ASPS.

Darryl J. Blinski, MD · Answer

There are ALWAYS consequences with any surgery. It is called the risk/benefit ratios. Unless you can live with the possibilty of a "sag" than do not do subglandular. But if the look is better above than going submuscular is a problem. Best to discuss again with your chosen surgeon.

Jeffrey D. Hoefflin, MD · Answer

The majority of breast implants are placed behind the muscle. In a submuscular position, there is less visible rippling, less palpability, a more natural result, less capsular contraction, etc. There are a few indications such as excessively loose breast skin in which a implant placed into a subglandular position might look better, however, you are loosing many more advantages. However, there are several factors that can answer your question. If your skin is already extremely loose, then expect over time that your breast skin will thin, the implant will be more visible, potentially your areola diameters might increase. A better solution that I typically use for most patients is a dual-plane augmentation pocket in which the implant resides both above and below the muscle in different locations of the breast.

Donna Rich, MD · Answer

Position or placement of implants either submuscular or subglandular does not determine how the skin will stretch over time. The quality of the skin, i.e. elasticity, your age and the size of the implants will impact the "sagging" of the breasts. Gravity also plays a large role over time.

Peter E. Johnson, MD · Answer

The fact is that most women do not sag with breast implants, under or over the muscle. The submuscular placement will hide the upper edge of the implant and reduce capsular contracture, as the breast will thin over time and the breast implant may begin to show through. Over many years a silicone gel or saline implant can develop a tight capsule and the breast can droop over the surface of the implant as the implant will push upward under the breast. Whether under or over the muscle, the capsule can be released and removed as your implants are replaced and restore the blending of the implant and the breast without a lift.

	Best of luck,

	peterejohnsonmd

Richard P. Rand, MD, FACS (retired) · Answer

I think that if you surveyed most plastic surgeons, they would agree that implants under the muscle are better for most patients because they look better, have less edginess, give better mammograms, and produce less scar tissue contracture problems. When placed above the muscle they really won't lift the breasts to any significant degree (contrary to some opinions) and they may drop into the breasts like a ball in a sock.

Do Subglandular Implants Start Sagging Sooner Than Submuscular?

Answers (7)

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