Is breast augmentation over the muscle ok?

I am having augmentation next week . I am 52 and have some sagging- moderate. My doctor is placing the implant over the muscle to fill the space I have lost. She said I have good breast tissue.I realize later I may still need a lift. I am anxious about mammograms. But she reassured me that is may take more work on the radiologist side but that they can still preform mammograms on women with implants over muscle. Advise?

Doctor Answers 17

Breast implants above the muscle

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Generally in my practice, I place implants beneath the muscle because there is less risk for the breasts hardening (capsular contracture). I also feel that the breasts look more natural with the implants below the muscle. Some doctors, frequently older ones, prefer to place the implants above the muscle.

Anatomic cohesive gel implants and biplanar placement is better

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Yes you want to avoid above the muscle implants. Not only can mammagrams be more difficult, but long term there are more problems.
There is more wrinkling and rippling. Capsular contracture rates are higher. The breast can stretch out.
An anatomic cohesive gel implant can help with mild droop. Also biplanar placement can allow the implant to be placed to fill more of the droop but still have superior pole cover for the advantages of muscle cover.
An above the muscle implant in a 52 year old can look very fake as well.
If the droop is more advanced a mini or peri areolar lift can also be considered. A slightly larger implant will also correct more droop.
But avoid above the muscle implants if you can. Although they look fine at first, later the results are not as good.

Avoid over the muscle implants

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Placement of pre-pectoral implants in sagging breasts is the worse possible combination. There is no support for the implant and the breast will sag even greater after this procedure done. You are setting yourself up for complications requiring revision. Many women fear lifts because of the ugly vertical scars. For that reason, a new technique has been developed called The Mini Ultimate Breast LiftTM. Using only a circumareola incision it is possible to reshape your breast tissue creating upper pole fullness, elevate them higher on the chest wall and more medial to increase your cleavage. Aligning the areola and breast tissue over the bony prominence of the chest wall maximizes anterior projection and may eliminate the need for implants. I always recommend small round textured silicone gel implants placed retro-pectoral since they look and feel more natural, are more stable, less likely to ripple or have complications needing revision.

Best Wishes,

Gary Horndeski, M.D. 

Gary M. Horndeski, MD
Texas Plastic Surgeon
4.6 out of 5 stars 230 reviews

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Over the muscle, pre-pectoral implants

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The overwhelming superiority of sub-pectectoral implant placement over pre-pectoral implants has been demonstrated in clinical studies over the last 20 years. I think that the absolute worst case scenario for using pre-pectoral implants is the situation which you are describing. It is a seductive mistake to use a larger implant in to fill out a droopy breast in the pre-pectoral position in the hope that it will support a breast and prevent a breast lift, particularly in a 52 year old woman, especially if you have had children and breast fed. Even if you have good tissue quality at this time, there is going to be attenuation of this tissue due to natural aging and this increases the risk of breast shape distortion through the years. There is actually a science to the art of providing a good lasting shape to the breast. You will likely need a breast lift and worse, the pre-pectoral implant will accelerate this by the weight on the breast tissue and the increased thinning out of breast. The gradual thinning out of the breast over time that increases the risk of upper breast implant visibility and rippling as well as the rock in the sock appearance. Dr. Singer mentions that there are some trade offs using prepectoral implants and this is true but the literature overwhelmingly supports the sub-pectoral plane. The marked increased incidence of capsular contracture in the pre-pectoral implant is another important reason to avoid this technique. It is not about the swinging pendulum in technique, this has been proven in clinical studies and I anticipate that additional clinical studies will further support the use of sub-pectoral implants. I cant tell you how many times I have to revise work the breast tissue has thinned out from pre-pectoral implant placement and the whole breast construct has been destroyed. This is an expensive operation. I advise you to do the procedure the best way the first time and avoid the risk of re-operation. A very prominent plastic surgeon has written extensively in our literature as how to avoid the pitfalls in choosing the wrong breast augmentation procedure and my wish is that more individuals in our specialty would heed his advise. I think that the jury is still out as to whether the stability of the form stable or gummy bear implant will mitigate against the firmness of this implant in thinning out breast tissue when placed in the pre-pectoral plane. I recommend that you obtain additional opinions of experienced expert plastic surgeons in your area. If this sounds a little dogmatic, I think that there are few reasons to use pre=pectoral implants and this would possibly be in a young athletic woman with ample breast tissue and the need for only a very small silicone implant. Even in this case the risk of capsular contracture is high and this risk is the same with form stable gummy bear implants as in textured soft silicone implants. 

Is breast augmentation over the muscle ok?

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Dual plane breast augmentation refers to breast implant positioning in the sub muscular ( pectoralis major)  positioned superiorly and the sub glandular position inferiorly.  This is the breast implant position used by the majority of plastic surgeons today and what I would suggest in your case.

I think it is in your best interests (and that of most patients seeking breast augmentation surgery) to have implants placed in the “dual plane” 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).

 However, as you may know, sub muscular (dual plane) breast implant positioning does have the potential downside of “animation deformity” ( movement/ distortion of the breast implants  seen with flexion of the  pectoralis major muscle.

Again, I think the advantages of sub muscular (dual plane) breast implant placement far outweigh the  potential disadvantages associated with breast implant  placement in the glandular position.

 I hope this, and the attached link, helps.

Breast implant over the muscle?

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There are pros and cons to the placement of breast implants in the “submuscular” position or the “subglandular” position, in which the implant is place behind the breast tissue, but in front of the pectoralis muscle. Either approach may produce a good cosmetic result in the appropriate patient. The following are the advantages and disadvantages of the various positions:

Submuscular implant” benefits:

o Usually results in a better appearance for naturally small breasted women

o Less tendency for seeing ripples of the implant.

o A more natural feel to the breast especially in slender women who don’t have much of their own breast tissue.

o Less interference with mammograms, although most radiologists take additional views no matter where the implants are placed.

o Lower rate of capsular contraction.

o Less of a chance of “bottoming out” where the implant bulges inferiorly and the nipple and areolas tend to appear excessively elevated.

Drawbacks of “submuscular implants”:

o Recovery usually takes a little longer and is more uncomfortable initially.

o 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.

o It is harder to achieve cleavage in women who have widely spaced breasts.

o The implants often ride higher on the chest.

Subglandular implant” benefits:

o A shorter recovery time.

o Less discomfort initially.

o No distortion of the breast when the pectoralis muscle flexes.

o Mild preoperative sagging can be improved, especially if no breast lifting procedure is performed.

o Easier surgical procedure.

o Larger implants can be placed.

Subglandular implant” disadvantages:

o The implant may be more visible.

o More visible rippling, especially in patients with a small amount of natural breast tissue.

o Generally, saline implants do not produce a good result in front of the muscle.

o Higher incidence of capsular contraction.

o “Bottoming out” in some patients.

o Some radiologists have more problems reading a mammogram with an implant in front of the muscle.

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. Discuss your concerns with a Plastic Surgeon who is Board Certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery.

Robert Singer, MD FACS

La Jolla, California

Robert Singer, MD
La Jolla Plastic Surgeon
4.6 out of 5 stars 22 reviews

Over the muscle is OK

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Over the muscle (sub-glandular) implant placement has been around since the very beginning of breast implant surgery. Your plastic surgeon, after examination and discussion with you, can offer you implant selection and placement options.

Sub-glandular implant placement is less painful and is used with gel implants (textured and smooth) in selected patients to obtain good cosmetic results. With saline implants, an acceptable result can be obtained if the patient has adequate breast to start with. Over the muscle implants are also less susceptible to displacement in patients with very well developed pec. major muscles. Later breast lifting may be of benefit if the breasts fall beyond what you find attrative.

Mammograms require additional views with breast implants...

Wishing you a pleasing result next week....
Best Regards,

Douglas J. Raskin, MD
Colorado Springs Plastic Surgeon
4.9 out of 5 stars 69 reviews

Implants can be placed over the muscle.

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Many years ago, most breast implants were placed above the muscle. That's how I learned 25 years ago. It worked reasonably well. What shifted the location below the muscle was the use of nearly exclusively saline implants beginning in the 1990's. Rippling became a big problem and the consensus opinion shifted to sub muscular, sub pectoral, or biplanar positions. Many other details regarding sub muscular versus sub glandular placement became issues. These included capsular contracture rates, mammogram problems, double bubble problems to name but a few. 
The pendulum is beginning to swing back to sub glandular. The game changers are the new anatomical shaped cohesive gel implants. In Europe, which had these implants over a decade, many if not most implants are placed above the muscle with excellent results. We in the US are relearning the lessons of sub glandular implant placement. One size and one approach does not fit all. Dogma takes a long time to resolve. Talk to your plastic surgeon; ask about the pros and the cons. Good luck to you!

Peter D. Geldner, MD
Chicago Plastic Surgeon
4.6 out of 5 stars 34 reviews

Implants above the muscle

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There are pluses and minuses to placing implants above or below the muscle.  Above the muscle is ok if you have enough soft tissue coverage.  Above muscle may obscure some mammogram examination.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Breast Implant Placement

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Dr. Rai's answer would make sense if breast implants were made out of breast tissue. They're not, however.  There is a lot known about short and long term effects of implants placed over the muscle including implant palpability, visibility, increased tissue stretch and subsequent sagging, higher risk of capsular contracture, and impairment of mammograms. On the other hand, subpectorally placed implants enjoy lower risks of the aforementioned problems, but have additional 'dynamic mobility' issues when contracting the pectoralis muscle, something that most women don't mind or even notice.

Contrary to Dr. Stoeckel's assertion that no consensus can be achieved, the annual Breast and Body Symposium in Santa Fe, run jointly by the ASPS and the ASAPS, poll surgeons about breast augmentation preferences. Typically, 90% plus surgeons place breast implants under the pectoralis major muscle, with the majority of them doing so exclusively.  Less than 5% of surgeons share Dr. Rai's views.

A common error is the concept that subglandular implants can lift a sagging breast. The improvement is always temporary, and typically the tissue stretch and implant settling increases breast sagging.  Breast sagging is not treated with breast implants or their placement. Breast sagging is treated with breast lifts.

You should be evaluated by a surgeon that performs all aspects of cosmetic breast surgery, including lifts, reductions, revision breast surgery, and not just implants. The minimum requisite credentials should be certification by the ABPS, and membership with the ASAPS. 

Best of luck! 

Gerald Minniti, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 100 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.