I am Thin but I Want Subglandular Implants. Is This a Bad Idea?

I offer patient's a simple analogy to illustrate what we mean:

Q: If you take a baseball and you cover it with a silksheet, what will it look like?

A: Like a baseball, you will even see the stitching.

Q: Now if you take that same baseball and cover it with a comforter what will you see?

A: It depends on how thick the comforter is but generally you will see a softly shaped lump.

So now the question is what do you have on your chest, silk sheets or comforters?

The way we determine this is by looking at your chest, if I can see your ribs (under the muscle) then you anatomy will have a hard time disguising the implant whether it is placed under or over the muscle and you are more likely better off with a silicone implant. Another way of measuring this is to pinch your upper chest skin (similar to pinch and inch of your waist on the Special K commercial). If you have less than an 2 cm (under 4/5 of an inch) than you have "silk sheets"

If you have a thicker skin/fat/breast layer that pinches over an inch than you have the option of going under or over.

Now the exception to the rule:

Q: What happens if you change the baseball to a volleyball?

A: All bets are off, whether you put it under or over the muscle it will not look natural.

The last issue is the implant shape. There are some anatomic shaped implants but I have generally found them to produce no significant difference in outcome with the exception of breast cancer reconstruction. However, this is my personal opinion
 

There are really great reasons to get breast implants over the muscle instead of under the muscle, but I have not noticed a big difference in the amount of pain the patient encounters. I would suggest Subglandular placement if you were a fitness professional or had another medical requirement. If you a fear of the actual incision you should talk that fear over with your plastic surgeon at your consultation. I usually choose to go under the muscle so it doesn’t interfere with the milk ducts and to provides more camouflage for the implants themselves. Talk to your surgeon about your concerns and questions.

Conventional wisdom states that if you want the most camoflouged edges to your implants and want to decrease the risk of capsular contrature then the implants should be placed under the muscle.  This gives the maximal amount of tissue covering the implants.  However, it is not a bad idea to place the implants in a subglandular position as long as you are willing to accept the trade offs.  Silicone implants would be a better choice to minimize the risk of visible rippling although in very thin patients there is simply no coverage to hide any contour irregularities.  Have a through discussion with your plastic surgeon so you understand both benefits and risks before choosing.  Good luck!

Although the standard thinking about breast implant placement is limited to over or under, there are really 4 options. The traditional under muscle placement, called "dual plane," does involve cutting the muscle off of its attachment to the ribs, which can lead to a number of problems. Another option is a split-muscle technique, which preserves all of the muscle's natural attachments and function while covering the upper part of the implant where it is most beneficial. Over-muscle placement can be done with a subfascial technique, which doesn't add much in the way of coverage but can add support and is useful in some situations. We use the subfascial and split muscle options a lot in athletic patients, who are often thin and muscular.

If you are very thin, you are probably better off having the implants placed in a biplanar pocket( partial submuscular).  It will help minimize the risk of rippling in the upper portion of the breast.

The key point to keep in mind is why you are having a breast augmentation. If you are not concerned about the visibility of the implant, the subglandular augmentation is fine. However, most women that I see are interested in a "natural" augmentation - larger breasts without the appearance that an implant is there. The pain and recovery associated with a submuscular implant placement may be longer but it is temporary. However, the visibility of the implant is a long term issue. Either way, as long as a patient understands that inadequate breast tissue coverage of an implant can lead to issues such as: palpable edges of the implant, rippling, thinning of the skin, and a poor cosmetic result, and they are alright with those risks, then a subglandular augmentation is certainly possible.

Regarding: "I am Thin but I Want Subglandular Implants. Is This a Bad Idea?
I am very thin with little breast tissue, but desire subglandular silicone implants, mostly because I am afraid of the pain and object to the idea of cutting into my muscle. Is this a bad idea?"

Cosmetic Surgery, in general and Breast Augmentation, in particular, is not a binary choice (0 vs. 1, light vs. dark, yin vs. yang) or good vs. bad. Instead, it is a choice between compromises and settling for the LOOK you are willing to accept and the one you are not willing to accept.

As you know ALL breast implants are imperfect; they all ripple and fold when held upright sideways. The rippling is seen MORE with saline than with gel implants. As a result, the MORE soft tissues we can pile up on the implant, the more we can camouflage and cover up the inherent complications of the breast implants. As a result, women with ample breast tissues (IE the ones who do not need breast implants) have natural results because the implant flaws can be hidden by breast or breast and muscle tissues. On the other hand, in thin women with a shortage of breast tissue, the (Pectoralis major) muscle is the only reliable cover implants can have.

Should you choose to go over OVER the muscle / under your (under-developed breast) gland, you will have the implant pretty much exposed under the skin folds and all. While choosing a gel implant is certainly a much better choice in your situation than a saline breast implant, it will leave you with palpable and visible breast rippling.

Do you want to have larger breasts with palpable and visible folds and ripples?
Do YOU think it is a BAD idea?

The choice is yours. Think it over and decide what look you are trying to achieve.

Good Luck.

Dr. Peter Aldea

There is not a right or wrong answer for this question. You will find surgeons which will tell you that one or the other are best for you. My recommendation is to obtain several Board certified (by the American Board of Plastic surgery) surgeons consultations, before making a decision.

Pain is something relative, some patients will have lots of pain, others will have none. Submuscular placement its more painful, however most patients (7 of 10) will be pain free in 10 days.

Implant visibility is most noticeable in thin patients with subglandular implants, saline worse than silicone, in some patient rippling and wrinkles of the implants may become quite visible. Capsular contracture is most common in subglandular implants, and if this is present then the implants are more visible.             After you understand the pro and the cons for each approach, you will be able to make an inform decision.

After I explain all of the above to my patients, I perform mainly under the muscle augmentation.

Breast implants were not always placed under the muscle, and even today perhaps one third are not. You are right in that the procedure takes a longer recovery, however submuscular implants are worth the effort for most because they dramatically reduce the 'show through' of the implant, and reduce the rate of capsular contracture as well.  Only over time will you learn if the subglandular implant was a bad idea for you. A cohesive gel implant especially can look round and stuck on with thin cover to hide the edges. A subglandular implant can work out for you if you are comfortable with the trade-offs. I would suggest a smaller and lower profile, less cohesive, gel implant for the most natural flow and softness, and a bit of good fortune.

Best of luck,

peterejohnsonmd

Very hard to answer without a posted photo. Best to discuss with a boarded surgeon in person. Best of luck from MIAMI Dr. Darryl J. Blinski, 305 598 0091