Where is the Best Placement of Implant when Dealing with Constricted Breasts? (photo)

Was told I have contricted breasts. I have 2in of tissue under my areolas and told it would be best if silicone implant was placed over the muscle (subgladular) and my lower breasts would be scored. I'm really worried about capsular contracture. Am I doomed to have Capsular Contracture because of the position of the implant & would scoring also increase my chances? Is it possible to go under the muscle and still have good results? Does scoring incr chances of bottoming out? Am I headed for compl

Doctor Answers 20

Implant Placement and the Constricted Breast

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Thank you for sharing your photos.  I would concur with you that you indeed have a mildly constricted breast.  This does make your case a bit more challenging.   However, do not worry - I think you still can achieve a very nice result!  To give you formal recommendations would require a formal physical exam so I could actually assess the distribution of your tissue, your skin quality, and actual degree of ptosis (sagging if any).  Most likely, I would recommend a dual plane augmentation where the upper half or two-thirds of the implant is under your pectoralis muscle and the lower pole of your implant is above the muscle.  The dual-plane technique is a "sister" to the tradtional under the muscle coverage.  In addition, I may recommend a periareolar approach to 1) perform the dual plane augmentation with silicone gel implants and 2) perform a periareolar lift if needed and 3) perform a radial release of your breast tissue if needed (as my colleagues have suggested, sometimes there are internal bands in your breast tissue that need to be released - these bands can be the cause of your breast constriction). Please visit with an ASPS member surgeon in your area to learn more about your options. 
Best of luck! Dr. Basu Houston, TX

Treatment of Constricted Breast

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You have a fairly mild form of a constricted breast in that the problem is mostly a tight lower pole of your breast with a small amount of sagging (based on these photos). I think you would do well with silicone breast implants placed in a partially sub-muscular pocket (dual plane approach) while lowering the breast fold by 1- 2 cm. You would not need extensive scoring, just release of any horizontal constricting bands just above the breast fold. Also, don't pick an implant with a base diameter (width) that exceeds the natural width of your breast. There are risks associated with lowering the breast fold ("double bubble", implant malposition) but they can be kept reasonably low if your surgeon does not get too aggressive with the breast fold manipulation.

Joseph Fata, MD
Indianapolis Plastic Surgeon
5.0 out of 5 stars 105 reviews

Tuberous Breasts and Breast Augmentation

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Hello Houston3058,

You have mild to moderate constriction of the lower pole of your breasts, a lesser form of 'tuberous breasts'.  Regardless, it does present with some difficulties in breast augmentation. Here is a line of reasoning to follow:

Like any sagging breast, subglandular placement of the implants does not help, therefore should be avoided and subpectoral placement performed.  That will eliminate much of the risk of capsular contracture. Your breasts do require a mastopexy, which will reposition the nipple areolar complex upward, and giving your breasts more lower pole visibility and presence.

Scoring of tissue is a frequently performed but outdated method of skin expansion.  It will only make the tissue covering your breasts thinner than they already are going to be after augmentation, and will not really contribute to any improvement to your breast's appearance, that is what the mastopexy is for.  Breast implants alone will expand the lifted breast well enough.

Finally, choice of implant size and projection is crucial.  Unfortunately, your constriction limits the size of the implant that should be used, and using an improperly sized (too large) implant will not only lead to capsular contracture, but also 'double bubble' deformity and implant rippling due to unpredictable tissue stretch, both of which are much more likely in women with your breast type.  Similarly, high profile implants should be avoided as well.  Once again, high profile means the opportunity to stuff more volume in a smaller space, something that will probably lead to trouble in your type of breast.

You should see a few surgeons that are not only certified by the American Board of Plastic Surgery, but are also members of the American Society for Aesthetic Plastic Surgery and have great reputations for complex breast implant surgery.

Best of luck!


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

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Pocket placement for constricted breasts

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There is no question that constricted breasts are more of a challenge when considering augmentation mammaplasty. That does not mean,  however that  you are destined for complications. Scoring of the breast tissue to spread it out does no increase your risk for capsular contracture.  I prefer to use a dual plane for  breast augmentation which keeps the muscle over the upper portion of the implants and you keep the advantages of implants under the muscle. This technique works for constricted breasts as well.

James McMahan, MD
Columbus Plastic Surgeon
4.8 out of 5 stars 40 reviews

Constricted (Tuberous) Breasts

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Thank you for the question and pictures.

Constricted (tuberous breasts) generally have a very narrow base,  a short distance from areola to inframammary fold,  a tight (constricted) lower pole of the breasts,  a relatively wide space between the breasts,  a "puffy" and areola and some degree of ptosis (drooping).  

Generally, the procedure involves breast augmentation with areola reduction / mastopexy procedure.  I prefer the dual plane ( partially submuscular)  positioning of implants. The distance from the inframammary fold is increased (to create a more rounded out appearance). Proper implant positioning improves the distance (cleavage) between the breasts. The areola reduction helps to treat the pointed and "puffy" appearance of the areola.

In the most severe cases of tuberous breast, a more complete breast lift may also be necessary.   I think that you will benefit from some breast lifting as well.  

I advise patients undergoing this type of surgery that it will take  months to see the final results of surgery and that  and that revisionary surgery is more likely  for them than in patients who do not present with tuberous (constricted) breasts.

 I hope this helps.


Pocket selection and constricted breasts

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There is still some controversy in regards to which is the best pocket to use when treating patients with constricted breasts. Traditionally only subglandular (above muscle) pockets were recommended along with inferior pole scoring with or without a mastopexy. Many surgeons are now getting excellent results with subpectoral pockets as well. Pocket selection is probably not near as important as adequate inferior pole scoring. Scoring does not increase one's chances of developing capsular contracture.

Kelly Gallego, MD, FACS
Yuba City Plastic Surgeon

Augmentation and constricted breast tissue

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It is important to note that not all constricted breast syndrome cases are the same.  Each patient and each set of breasts require different treatment based on the surrounding tissue as well as the goal that is desired.  One of the more important decisions that you should make is which surgeon to go to as not all plastic surgeons have equal experience with constricted breast tissue.  Subglandular or subfascial breast augmentation does not necessarily expose you to higher capsule contracture rates.  Ask plastic surgeons who perform both under as well as over the muscle is relatively equal amounts and they will tell you that capsule contracture is pretty much the same. 

All the best,

Dr Repta

Remus Repta, MD
Scottsdale Plastic Surgeon
4.9 out of 5 stars 173 reviews

Breast augmentation in constricted breast

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Your breasts are constricted, which means that the lower breast is shorter and tighter than normal. In order to provide you with a satisfactory result, the loer pole must be released and lowered. I would actually place the implant under the muscle, releasing the lower edge of the muscle so that the implant can fill the lower pole. I would make cuts in the tissue if it remained tight once streteched by the implant. One has to be careful not to release the inferior fold of the breast too musch or "bottoming out" can occur. It is also important not to use too large an implant to try to stretch the breast, as this can increase the risk of bottoming out, which means that the breast implant falls too far below the fold. 

Please make sure that your surgeon has experience with this type of augmentation. It is definitely more challanging that a routine augmenation.

Karen Vaniver, MD
Kennewick Plastic Surgeon
5.0 out of 5 stars 38 reviews

Above or below muscle placement of implants for constricted breasts?

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Constricted breasts do present challenges for breast augmentation. The short "constricted" distance from areola to the inframammary fold must be increased or, since the bottom of the implant lies at this fold, the nipple will reside too close to the bottom of the breast mound and point down. The only way of increasing this distance is to lower the fold, and then one must release the constricting bands holding the breast tissue too narrow and too tight and try to obliterate the old fold so that there are not two creases! Although this is more challenging than a standard breast augmentation, we frequently get good results, but it is important to realize the inherent difficulties. To answer the question of implant placement, using a dual plane technique where the implant is still under the muscle (so as to get better coverage at the top to hide implant edges and wrinkling in a patient with thinner tissue AND perhaps reduce the risk of capsular contracture) but the muscle is released from the lower pole to allow better expansion of the implant into and stretching of the lower pole, we can get an equally good result without having to place the implant above the muscle. I hope that answers your question...good luck!

Breast Augmentation for Constricted Breast

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Scoring does not increase your risk for capsular contracture.  The risk for capsular contracture is not significantly different if the implant is on top or under the muscle. And yes, it is possible to place the implant under the muscle

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.