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

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).

Very interesting question.Subglandular and submuscular pockets both have their  upsides and downsides. A submuscular pocket is very rarely completely submuscular.Here are the pros and cons.1) A subglandular has a higher rate of infection, contracture, wrinkling and bottoming out in the future.2) A subglandular pocket is less traumatic, so there is less pain in the first few weeks. There is also little risk of animation deformity (implant moving when the chest muscle is flexed).3) A submuscular pocket has a lower rate of infection, contracture (hardening) and wrinkling.4) A submuscular pocket has a risk of muscle animation and a strong chest muscle can push the implants towards the arm pits.5) In the United States, >90% of plastic surgeons use a submuscular pocket.Looking at your photos, a subglandular pocket might prevent a snoopy deformity, but this comes with a risk of bottoming out over time. You do have some excess/loose skin below your areola. Another option might be a submuscular pocket with a tightening procedure to tighten the skin under the areola and prevent a snoopy deformity.You have several options, so continue gathering your information in order to make an informed decision.Good Luck!

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

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

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. 

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

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.
Semantics can be confusing.  When surgeons talk about placing breast implants "behind the muscle", they are usually referring to  "partial" or "dual plane"  positioning. In other words, all of these terms refer to the same sub muscular (as opposed to sub glandular positioning) positioning of breast implants.
Dual plane breast augmentation refers to the technique where breast implants are placed under the muscle superiorly and in the sub glandular  position inferiorly.  I think this is the best way to go for most patients. On the one hand, patients benefit from the sub muscular position with increased tissue coverage of the breast implant, less chance of encapsulation, less potential for rippling/palpability of the implants and less interference with mammography.
On the other hand, because the implants are not completely sub muscular there is the potential for less “distortion” of the breast implants with pectoralis movement. Generally, in my opinion, the breasts also look better with breast implants in this position.
I hope this helps.

You are so thin that the possibility of visible implant edges and possible rippling, even with silicone, is high with implants in the subglandular space. There is no increased likelihood of deformity with a properly dissected dual plane (partially under the muscle) pocket.