Should I get subglandular or submuscular 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 faster.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 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.In my practice, the vast majority of patients will have the implants placed submuscular for all the reasons listed above.With regards to your specific question, there is a benefit to placing implants subglandular in cases where there is some ptosis/sagging which will not be addressed via formal lift. A subglandular augmentation will align with a ptotic breast better than a high riding submuscular implant.Ultimately, if you need a lift you will likely be happier with a submuscular augmentation and a formal lift. This will give you a satisfying result that will last.
As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Dear New year_new boobs,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.Breast implant type and sizing selection is a complicated process and requires a detailed consultation that includes a discussion of your goals, a detailed examination, and a lengthy discussion. But the decision will always start and end with the patient. When it comes to sizing, we have all of our patients find 3 photos of their desired breast size. We ask for naked breast photos because clothing can obscure the true size (push up bras). Next, we consult with patients and go over the photos and take detailed breast measurements during a physical exam. Next, we using a sizing algorithm to determine a range of implants that will work based on the exam and the measurements.Lastly, during the operation, we use silicone sizers in the operating room to see how the size actually looks in the breast. We sit the patient up in the operating room, while asleep of course, and compare the sizer result with their desired look photos. If it is too small, we start the process over with a slightly larger implant. We don't stop until we get the perfect match.Of all of my breast augmentation patients, every one of them has been happy with their size due to this detailed and meticulous process. You don't want to invest time and money into a result that is either too big or too small.You should discuss your concerns with a board-certified plastic surgeon and make sure that your surgeon understands your goals.Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

hello thank you for your question and provided information as well.. based in your question and the picture you showed you are a good candidate for breast lift  with implant in your case for best result you can apply for position sub glandular , its recommended if you get a consultation in person with a plastic surgeon to determinate how many cc do you need to the better results.

Hello and thank you for your question. You are a great candidate
for a breast augmentation using a dual plane technique. There are several
advantages and disadvantages to over vs under the muscle.  Under the
muscle has the advantage of lower capsular contracture rates, less risk
of rippling, and better visualization with future mammograms.  Most
patients say that under the muscle also has a more natural look and
feel.    Make sure you
specifically look at before and after pictures of real patients who have
had this surgery performed by your surgeon and evaluate their results.  
Best wishes and good luck.
Richard G. Reish, M.D. FACS
Harvard-trained plastic surgeon

Hi. I do not like the placement over the muscles since breasts will fall within the year of the surgery. The best approach is to place the implants under both of the pectoral muscles that will kept them in place as if wearing a natural bra. This will avoid migration or displacement of the implants and give you a very natural look.International Member of the American Society of Plastic Surgeons (ASPS)
Member of the International Society of Aesthetic Plastic Surgery
25 years experience

Thank you for the question.  I think it is in the best interests of most patients seeking breast augmentation surgery to have implants placed in the “dual plane” or sub muscular position.  This positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look  of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability  of the implants (which may increase with time, weight loss, and/or post-pregnancy changes). The submuscular positioning  also tends to interfere with mammography less so than breast implants in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position. 
On the other hand,  sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants  seen with flexion of the  pectoralis major muscle)  that can be seen with breast implants placed in the sub muscular position.
 
Generally speaking, the best online advice I can give to ladies who are considering breast augmentation/lifting surgery ( regarding breast implant size/profile selection) is:
1. Concentrate on choosing your plastic surgeon carefully. Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you are looking for. ***Ask to see lots of examples of his/her work.
2. Have a full discussion and communication regarding your desired goals with your plastic surgeon. This communication will be critical in determining breast implant size/type/profile will most likely help achieve your goals. 
In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. For example, I have found that the use of words such as “natural” or "C or D cup" etc means different things to different people and therefore prove unhelpful.
Also, as you know, cup size varies depending on him who makes the bra; therefore, discussing desired cup size may also be inaccurate. Again, the use of computer imaging has been very helpful during the communication process, in our practice.
3. Once you feel you have communicated your goals clearly, allow your plastic surgeon to use his/her years of experience/judgment to choose the breast implant size/profile that will best meet your goals. Again, in my practice, this decision is usually made during surgery, after the use of temporary intraoperative sizers.
I hope this helps. Best wishes for an outcome that you will be very pleased with.

Dear New year new boobs,Hello and thank you for your excellent question. In general, we prefer to place implants in a submuscular position in order to minimize the risk of long term side effects, like capsular contracture and implant visibility/ rippling. It is best to answer your question during a face-to-face evaluation, when you can discuss your goals and expectations for the procedure, and you can have a physical examination to evaluate for that procedure. I recommend that you find a board-certified, or board-eligible plastic surgeon with whom you are comfortable. Be sure to have all of your questions answered during a face-to-face meeting with your surgeon, and review before and after pictures of similar patients whom have had this procedure. If you have any questions, call our office for assistance. Good luck!

Best,

Jon Ver Halen, MD FACS

Harvard educated plastic surgeon

Texas “Top Doc” 2017, 2018

RealSelf100

America’s Top Plastic Surgeons, Consumer’s Research Council, 2010 – 2018

BeautyAdvisor Top Contributor

Both the subglandular (on top of muscle) and submuscular (under muscle) approaches to breast augmentation are used today by plastic surgeons. There are advantages and disadvantages to each of these approaches. For the use of a sub glandular implant, most plastic surgeons would consider how much glandular breast tissue will lay above the breast implant to allow it to be more hidden. In thinner patients, with sub glandular implants, especially saline, visible wrinkling can be a problem. There are just a few advantages to the sub glandular placement. For the first few days or so, it is certainly less painful to put in a sub glandular than a sub muscular breast implant. The sub glandular placed implant will look more properly in position earlier without the overlying tension of the pectoralis muscle allowing the implant to ride higher in the chest for a few weeks. Also, in the case of a patient with a wide breastbone and the wish for a narrower cleavage, the placement above the muscle will allow for more movement of the implant towards the center of the chest thus narrowing the space between the breasts. In patients with thin overlying breast tissue, especially with larger implants, the outline of the implant is more visible through the tissues with the implant placed above the muscle. We do know that the rate of capsular contraction is higher in implants placed above the muscle than implants placed below. The sub muscular approach has a few advantages. One important one is that mammography is a little easier to do and to read when the implant is placed below the muscle. There is also less wrinkling, less visibility, and less rate of capsular contracture. Other than being more painful for a few days after surgery, another issue with the sub muscular placement is animation. When the pectoralis muscle is activated, it will push the breast implant upward as well as outward which can be visible through the skin. Another consideration in this choice of whether the implant is sub glandular or sub muscular is that in today's modern breast implant surgeries, most of the time, a dual plane approach is utilized. In this way, the upper part of the breast implant is placed below the muscle and the lower part can be placed either on top of the muscle or below the lining of the muscle called fascia. With this approach, the bottom of the implant in the sub muscular placement can be in the same place and position as if the implant was placed on top of the muscle. This is the technique used by most plastic surgeons today. Each surgeon has their own preference and I would recommend that you seek out the consultation with a board-certified plastic surgeon and asks them what their choices for you would be and why. Good luck with your surgery.