Should I choose subglandular or submuscular? I'm going with 475cc tear drop implants.

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 fasterSubglandular 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 when compared to subpectoral augmentation.Subglandular implants can also create the illusion of improved cleavage by preferential over-dissection of the central/medial pocket allowing the implants to be forced more to the midline. There is no limiting muscle as there is in a submuscular augmentation. 
Subpectoral Augmentation/Sub-muscular (“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.With regards to your specific question, there is no set limit for submuscular volume. The vast majority of patients in my practice, opt for submuscular round implants (as most cannot tell the difference). Over time, irrespective of your choice, your breasts will change. In submuscular augmentation, the breast mound will sag off the implant. In the setting of subglandular augmentation, the implant and breast mound will sag together. Neither is perfect or immune to the effects of gravity.
As always, discuss your concerns with a board certified plastic surgeon (ABPS).

hello thank you for your question and provided information as well.Based on your question, that will depend on how much your skin stretches in your case its much better for i can hear submuscular.
ideally, consult your certified plastic surgeon to see you and discuss your case again.

I always favor submuscular whether complete or dual plane. I have been practicing long enough to remember the problems of subglandular pockets. If you have concerns, get an in person second opinion. Good luck.

Dear leeshore77,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, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Hello leeshore77,
I appreciate your questions! One of the most important decisions prior to a breast augmentation procedure with implants is the selection of the breast implant pocket. In this respect, I favor Dual-Plane over both Partial Submuscular (under the muscle) and Subglandular (above the pectoralis muscle of the chest) breast augmentation, because Dual-Plane placement allows for a more natural appearance while keeping the benefits of having the muscle cover the implant. There’s also a reduced tendency for the breast implant to ride high, as well as a reduced tendency for the implant to lateralize. Among the disadvantages of placing the implant over the muscle (subglandularly) are the following: 1) implant palpability may occur when the patient’s breast soft tissues are very thin; thus, it is vital that the plastic surgeon assess the soft tissue of the breast before deciding to place the implant subglandularly, and 2) there’s a higher risk of seeing ripples (especially with saline breast implants) and capsular contracture (almost 1 in 4 women). On the other hand, under the muscle implant placement is typically more painful, have a significant risk of double-bubble or snoopy deformity of the breast, and it’s associated with a longer period of recovery, and more post-operative discomfort. With regards to size, the maximum implant size would depend on the base diameter of your breasts which will be measured by your plastic surgeon. Going beyond the recommended size based on your breast parameters is associated with higher complications. Discuss your thoughts about a future pregnancy and breast-feeding with your plastic surgeon in advance of your surgery date. This information may affect your choice of incision and implant placement. For example, a periareolar incision (around the edge of the nipple) may disturb your milk ducts. Hope this is helpful! Dr. De La Cruz. 

If you are considering more children in the future, I would recommend submuscular placement of the implant to keep your blood supply in tact between the muscle and the breast.  The anatomic implants are very nice and give nice post op shape.  Submuscular placement will also lower the rate of capsular contracture.  Good luck

To most of surgeons placed breast implants underneath the chest muscle with a dual plane technique through an inframammary crease incision under the breast. Placing the implants on top of the chest muscle does increase the risk of capsular contracture. Shaped or textured breast implants have a thicker shell and can sometimes be palpable and can sometimes footboard turned in the pocket. There is also the very unusual and rare chance of breast implant associated Hypoplastic Large Cell Lymphoma which is not related to smooth walled silicone gel implants.

In my opinion, the only advantages of subglandular implants are a less painful more rapid recovery and a more rapid achievement of the final look. That's about all. Otherwise, the mammograms are more accurate later in life, there is less scar tissue, the implants stay up with better upper pole fullness and less "ball in sock" look when they are submuscular. For those reasons, I have never gone subglandular in a first time patient in 30 years of doing this.