Subglandular versus submuscular: Are there cases when subglandular is better? (Photos)

Question

Are there times when the subglandular is the better method? I’ve been to two consultations. One doctor recommended a partial submuscular augmentation, while the other one said the he recommended subglandular to avoid the snoopy effect. Neither one felt I could go completely under the muscle.

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.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/Dual Plane (“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. This is also known as a dual plane (due to the fact following muscle release half the implant is under the muscle while the lower pole is not). Complete submuscular coverage is rarely performed due to the distorting pull of the muscle.
With regards to your specific question, subglandular is preferred when animation is a major concern, when there is ptosis present but the patient is unwilling to consider a lift (snoop deformity), or when a lack of muscle strength will be an issue.Based on your photos alone, you would appear to be an excellent candidate for  a submuscular 
As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Kenneth Hughes, MD · Answer

Submuscular or dual plane is a better choice for a number of reasons including reduced risk of capsular contracture and greater implant coverage. Tissue thinning and implant visibility tend to be more prominent with subglandular placement. As a bodybuilder, I augment professional athletes frequently.  I think for those people in whom the living is made by athletic performance, the implant can be placed above the muscle.  Kenneth Hughes, MD, ABPS Board Certified Plastic SurgeonLos Angeles, CA

Robert Singer, MD · Answer

There are essentially two choices for breast implant placement: sub-glandular (under the breast tissue and in front of the chest muscle – the pectoralis muscle) or sub-muscular (under or partially under the chest muscle). The best location depends on many factors including: tissue thickness, weight, desired outcome, and individual anatomy. Each position has advantages and disadvantages:
  
Subglandular implant benefits:
  
A shorter      recovery time.
  Less      discomfort initially. 
  No distortion      of the breast when the pectoralis muscle flexes. 
  Mild      preoperative sagging can be improved, especially if no breast lifting      procedure is performed. 
  Easier      surgical procedure. 
  Larger      implants can be placed. 
  Subglandular implant disadvantages:
  
The implant      may be more visible. 
  More visible      rippling, especially in patients with a small amount of natural breast      tissue. 
  Generally,      saline implants do not produce a good result in front of the muscle. 
  Higher      incidence of capsular contraction. 
  “Bottoming      out” in some patients. 
  Some      radiologists have more problems reading a mammogram with an implant in      front of the muscle. 
  Submuscular implant benefits:
  
Usually      results in a better appearance for naturally small breasted women 
  Less tendency      for seeing ripples of the implant. 
  A more      natural feel to the breast especially in slender women who don’t have much      of their own breast tissue. 
  Less      interference with mammograms, although most radiologists take additional      views no matter where the implants are placed. 
  Lower rate of      capsular contraction. 
  Less of a      chance of “bottoming out” where the implant bulges at the lower aspect of      the breast and the nipple and areolas tend to appear excessively elevated.      
 Submuscular implant disadvantages:
  
Recovery      usually takes a little longer and is more uncomfortable initially. 
  There may be      an “animation deformity”, which is a temporary distortion of the breasts      when the pectoralis muscle is flexed. Body builders and weight lifters      generally prefer implants in front of the muscle. 
  It is harder      to achieve cleavage in women who have widely spaced breasts. 
  The implants      often ride higher on the chest.
 Actually, most patients who have breast augmentations today have breast implants placed in a combination or “dual plane” position. This approach has the same benefits and disadvantages of a total “submuscular implant”, but with a lesser tendency to ride high on the chest wall. The disadvantage as compared to a total “submuscular implant” is a higher tendency for bottoming out.
  
The ideal placement in any particular patient depends on their particular anatomy and understanding of the pros and cons of each approach and desired outcome.. 
  
Keep in mind, that following the advice from a surgeon on this or any other website who proposes to tell you what to do based on two dimensional photos without examining you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of each operative procedure may not be in your best interest. I would suggest you find a plastic surgeon certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person.   
  
Robert Singer, MD  FACS 
  
La Jolla, California

Daniel Barrett, MD · Answer

Dear momof4est2008,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

Don W. Griffin, MD · Answer

Based on your pictures, I don't think that you have to worry about having a "snoopy effect" based on your breast shape. Subpectoral placement, dual plane, and partial sub muscular are all terms used to describe placing the upper part of the implant under the muscle with the lower part only covered with breast tissue. There are differing degrees of how much muscle coverage there is, but all are essentially the same as far as pros and cons. Implants placed under the muscle have a lower incidence of capsular contracture (scar tissue), make it easier to do mammograms, and tend to have less stretching out long term than implants placed subglandularly.

Subglandular versus submuscular: Are there cases when subglandular is better? (Photos)

Answers (8)

Answer: Implant placement

Answer: Implant placement

Answer: Subglandular versus submuscular: Are there cases when subglandular is better?

Answer: Subglandular versus submuscular: Are there cases when subglandular is better?

Recommended reading

Everything you need to know about Breast Implants

Our mission is to create a world where every investment in modern beauty is Worth It.

Subglandular versus submuscular: Are there cases when subglandular is better? (Photos)

Answers (8)

Answer: Implant placement

Answer: Implant placement

Answer: Subglandular versus submuscular: Are there cases when subglandular is better?

Answer: Subglandular versus submuscular: Are there cases when subglandular is better?

Browse related questions

Recommended reading

Everything you need to know about Breast Implants

Our mission is to create a world where every investment in modern beauty is Worth It.