Under VS over the muscle. What's the difference? Undecided if I should 600cc or 650cc?

Question

I'm 41 yrs old, 5'8 and 140 lbs. not sure if that will be to big for my body frame. I want the fullness and I want cleavage. Appreciate your opinion?

Jaime S. Schwartz, MD, FACS · Answer

I appreciate your question.

The best way to determine implant size is based on chest wall measurements that fit your body.  Once we determine that we can choose the profile based on what you want or need to achieve.

Implants under the muscle, there is less risk of capsular contracture.  Anatomic implants tend to give a more natural shape with more nipple projection.

The best way to assess and give true advice would be an in-person exam.  Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.

Best of luck!

Dr. SchwartzBoard Certified Plastic Surgeon

#RealSelf100Surgeon

#RealSelfCORESurgeon

Jerome Edelstein, MD · Answer

Hello,There is very little difference between these two sizes. Placement can change how they sit/look. Your existing tissue and anatomy will determine where your Plastic Surgeon thinks they should be placed. Be sure to communicate your goals and expectations clearly. My patients find it helpful to try on the implant sizers in the office with a form fitting T-Shirt in order to get a feel for them.All the best

Steve Laverson, MD, FACS · Answer

The difference is implant positioning.  Only about 50% of your implant will be sub-pectoral (deep to the pectoralis major muscle) if "under" the muscle.  This may diminish the incidence of capsular contracture for you, and as other responders suggest, camouflage implant edges better, so they'll be less visible when your swelling dissipates.  The type of implant used affects implant edge visibility and rippling though.  Form stable implants don't ripple if placed in an appropriately sized pocket, and can therefore be positioned subglandular with less concern about implant edge visibility and rippling.  These are questions and issues to resolve with your surgeon prior to your procedure.  The difference between 600 and 650cc in volume is just over three tablespoons.  From the standpoint of implants in your body, where is this 50cc difference distributed, in width or in projection?  Dimensions are much more important than volume when deciding upon implant size.

Jane M. Rowley, MD · Answer

50cc is less than two ounces, I do not think you will notice a significant difference in those two implants.  Many people will advise you to go larger because patients will often say they wish they had gone larger. In my opinion going smaller makes sense, especially with very large implants.  Less weight on the tissue gives you a better long term result.  Also, under the muscle provides a more natural result with  a better long term result, in my opinion.  Good luck, Jane.

Steven J. Rottman, MD, FACS · Answer

Thank you for your question. "Tissue based planning" relies on your chest and breast measurements and is the safest way to ensure good long term results. Your surgeon should determine what size and projection are necessary to give you your desired result based on your body's measurements. The best way to assess and give true advice would be an in-person exam. Please see a board-certified plastic surgeon that specializes in aesthetic breast surgery. Hope this helps and good luck with your surgery.

Martin Jugenburg, MD · Answer

Thank you for your question!

Your queries can best be addressed with an in-person
consultation and a breast exam.

The implant size has to be chosen in relation of your
preferences, your breast anatomy, characteristics and boundaries. Only when the
implant is tailored to your breasts, then you can get natural-looking results.
The more you deviate from the proper fit, the more fake your breasts will look.

An evidence-based method to
identify the implant size is called tissue-based planning. The planning takes
into account the effects of implants on tissues over time, risks of excessive stretch, excessive
thinning, visible or palpable implant edges, visible traction rippling, ptosis
(Sagging), and breast tissue wasting. The planning involves making certain
breast measurements such as the base width of the existing breast tissue,
breast skin stretch, and nipple to inframammary fold distance. The implant size
that will be identified will be the one which will adequately and appropriately
fill your breasts while keeping long-term results under consideration.

Finally, with regards to the pocket of implant
placement, I would like
you to know that the decision to go behind the muscle or
over the muscle has to do with the amount of soft tissue coverage – “padding”
you have under the skin. Choosing a pocket that is tight with sufficient soft
tissue coverage not only prevents implant visibility, palpability, and risks of
excessive stretching on the breast, but also excessive implant movement into
the outer or inner sides of the breasts. A hand-in-glove fit for the implant
allows for a natural and long-lasting result. Your surgeon will do a pinch test
in the upper pole of the breast to see how much “padding” you have. If you have
less than 2 cm, then you do not have much padding and it would be best to go
under the muscle. Generally speaking, if your ribs are visible under the
muscle, then you do not have much “padding.” If however, you have more than 2
cm of tissue, then you have the option to go over the muscle or under the
muscle

Which pocket do you prefer?

OVER THE MUSCLE

If you are hoping to fully preserve the
functionality of the pectoralis major muscle due to athletics or body building,
or if you have a shapeless, constricted, tuberous, sagging breasts without
cleavage, then over the muscle may be a better option.

·        
Over the muscle
implant placement causes less trauma to the chest muscles, and the implants
will not be subjected to any pressure or injury due to muscle movement.

·        
The implant can
directly apply pressure on breast tissue to shape the breasts.

·        
However, over the
muscle implant placement may have higher risks of breast tissue wasting,
interference with mammography, and capsular contracture compared to under the
muscle placement.

·        
Higher risk of
implant visibility and palpability is possible if you are thin, and this can be
fixed used fat grafting where areas with less tissue coverage are filled with
your own fat to provide better contour and coverage.

UNDER THE MUSCLE

Under the muscle (partially submuscular)
is a preferred option for many surgeons because the muscle helps to maintain a
slope for the upper pole while allowing for a curvature in the lower pole,
while over the muscle will mostly make your breasts appear round and augmented.

·        
In thin patients,
additional coverage by the muscle reduces the risk of implant visibility in the
upper and inner sides of the breasts. It also reduces risk of synmastia, and
provides less interference with mammography and breast imaging. It also brings
lower rates of capsular contracture.

·        
However, under the
muscle implant placement may allow the chest muscles to put pressure on the
implant distorting the breast shape and position in the long-term. You may
experience more pain following surgery due to the dissection of some muscle
attachments and you may lose strength while flexing your chest muscle and is
not suitable for athletes and body builders.

All
this being said, if you trust your surgeon and their judgment and the
decision-making method used to choose the implant size, then you should be in
good hands. Make sure to fully and comprehensively share
your desires, expectations, and concerns to avoid miscommunication and
post-operative concerns/regrets.

Hope
this helps, and best of luck!

Curtis Wong, MD · Answer

The implant can be placed either above (subglandular) or below (submuscular) the pectoralis muscle.  My recommendation is to place the implant under the muscle because the muscle provides added protection of the implant from superficial skin infections or injury, provides more accurate mammography when evaluating lesions with muscle between it and the implant, adds fullness to the upper pole, covers any upper pole rippling, and diminishes the risk for capsular contracture.  It will weaken your chest muscles and this usually goes unnoticed by most.  Placement under the muscle will result in visible movement of the breast mound with any contraction of your chest muscle. It may also deepen your armpit making shaving challenging. The one exception I have in placement involves body builders or others who are planning to flex their muscles in front of audiences.  Placement above the muscle diminishes the chance of implant movement with muscle flexion and is anticipated to hurt less and allow a faster recovery but it’s been my experience that subglandular placement can take on the “rock-in-a-sock” look or droop as time goes on (especially with smooth round implants).

Andre Levesque, MD · Answer

Thank you for your question.

Please see several board certified plastic surgeons that can examine and speak with you about your goals.  They will measure your chest dimensions, amount of breast tissue, and nipple position among other things to develop a plan for your augmentation.  The volume of the implant is in my practice one of the least important part of the process as I value base width, height (if using shaped implants), projection, and saline versus silicone over specific volume implant.

The reasons to go under the muscle typically involve wanting to achieve better implant coverage as in patients with little breast tissue.  This approach is the more common approach, in the United States, but I would consider above the muscle or subglandular /subfascial to be regaining popularity.  Above the muscle placement has advantages of less pain and no animation deformity and possibly more of a lift effect.  Under the muscle which would likely be a partial submuscular or dual plane approach would allow more coverage in the implant particularly in the upper pole of the breast.

A 600 or 650 cc may be an appropriate size for your frame but it is impossible to tell without an in person exam.  I can say from personal experience the difference between a 600 or a 650 implant is imperceptible by trained plastic surgeons and I would recommend not stressing over 50 cc.  Many surgeons when faced with that very question recommend the larger number to avoid a patient regretting not going larger.  A 650 cc implant would be in the larger category for primary augmentation in the United States where averages based on region are probably in the 300-400 cc range and trending downward.

Best,

Dr. L

Johnson C. Lee, MD · Answer

There are pros and cons to the location of the implant. Benefits to putting the implant above the muscle is less implant movement with muscle contraction and easier surgical dissection. Benefits to putting the implant below the muscle is less scar tissue formation and less visible rippling from the implant. There are other reasons as well and some surgeons prefer one pocket to the other. In terms of sizes, a 50cc difference is very minimal at the 600cc level and it is best to allow the surgeon to decide which one looks better during surgery when the implants can actually be tested and placed. It is important to have a thorough examination and discussion with your surgeon prior to the procedure so that all your questions are answered and you can make an informed decision. Hope this helps!Johnson C. Lee, MD Plastic Surgery

Robert M. Kachenmeister, MD · Answer

Thank you for asking Just based on your body measurements (mainly your height) 600cc's is not out of the question. Of course it depends on how wide your hips are as to whether these will look proportional. As for the cleavage it really depends on your naturally occurring cleavage preoperatively. I almost always suggest going under the muscle as it will give a more natural upper pole (fullness) of the breast. We would love to see you for a complimentary consultation in our Mission Viejo or Newport Beach office to go over all of your options. Or please feel free to message us with your photos and any other questions you might have. Thanks and best of luck! Dr. Kachenmeister, (Dr. K) MD.

Under VS over the muscle. What's the difference? Undecided if I should 600cc or 650cc?

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