Subglandular vs submuscular implant for me? (Photos)

Hi I'm getting a lift and also argumentation is trying to decide between under or over the muscle? My doctor recommended lift, 500cc silicone subglandular, but I did some reaserch and found out that subglandular sag down and I would like to only go with one surgery. Ps. I'm 20 so my saggying is from gravity I would think

Doctor Answers 12

Lift before augmentation

My personal recommendation [based on your photos and what appears to be significant ptosis (nipples pointing downward) and pseudoptosis (breast hanging over the fold underneath), as well as what appears to be a considerable amount of breast tissue] is to do a breast lift first which will give the breasts a nice perky shape with better symmetry. 

After 6 months or so,then go back with the augmentation at which time your surgeon can advise you on subglandular or submuscular.

I think there is a good chance you will not even need or want an implant after getting a good result from the lift, but if you do then you and your plastic surgeon will be in a better position to choose the size of the implant that will give you the volume you desire.

I believe, in your case, in the long run you will get a better result doing a 2-stage approach, especially if you want 500 cc implants, as I think it will be extremely challenging to get a good shape with that amount of additional volume in a single operation.


Chattanooga Plastic Surgeon
5.0 out of 5 stars 26 reviews

Breast augmentation and lift candidate, some advices:

Thank you very much for enquire.
After having analyzed all the information and photos provided to us, I realize that you have very sagging and small breasts. In this regard, you need volume (implants) and projection (the lift): Breast Augmentation w/Breast Lift.
I recommend you to use microtexturized highly cohesive silicon implant ("gummy bear" implants), with high projection, and 550ml will be excelent on you, to fill the breasts properly.
Finally, to perform the breast lift I recommend a Periareolar Round Block Breast Lift ("Benelli mastopexy"), which has an unnoticed scar around the areola, and if we see (in the surgery) that we can't obtain adecuate projection just with the Benelli Lift, we have to perform a "Lollipop breast lift".
Respectfully,
Dr. Emmanuel Mallol Cotes.-

Emmanuel Mallol Cotes, MD
Dominican Republic Plastic Surgeon
4.7 out of 5 stars 174 reviews

Subglandular vs submuscular implant for me

The risks of capsular contracture are lower with the implant below the muscle. In addition, putting the implant above the muscle will put more strain on your skin and might accelerate the repeat sagging of the breast.

Julio Garcia, MD
Las Vegas Plastic Surgeon
4.8 out of 5 stars 26 reviews

Subglandular vs submuscular implant for me?

In most cases, under the muscle is a better option but there are some advantages to each approach. May want to discuss in more detail with your surgeon. 

Karol A. Gutowski, MD, FACS
Chicago Plastic Surgeon
4.9 out of 5 stars 65 reviews

Subglandular vs submuscular implant

Hello, based on the photos I would perform a breast lift combined with submuscular round implants.  If you are having the lift the position of the nipple will already be corrected so the implants can be placed under the muscle.  There is more tissue coverage with this type of pocket.

Subglandular or submuscular

You are best to follow your plastic surgeon's advice.  There is a lot of controversy about the placement of implants above or below the muscle.  I disagree that subglandular tends to sag more -  the reverse sometimes happens when the implant is under the muscle because the muscle can push the implant down.  I believe that an implant looks more natural above the muscle when a patient has enough natural breast tissue (as you do) and I believe that an implant looks more natural under the muscle when a patient has very little breast or fat to cover the implant edges.  There are pros and cons to each choice.  When implants are placed under the muscle, the disadvantages are 1. the animation deformity which occurs when the muscle contracts, 2. wider cleavage (and you already have fairly wide cleavage, and 3. the possibility of a double bubble deformity.  There is no one right answer for everyone.  If there really is a higher rate of capsular contracture above the muscle, it is minimal.

Subglandular or submuscular implants

Personally, with a lift, I prefer implants under the muscle. This offers an extra layer and less risks.

An exam and consultation with a plastic surgeon is recommended to discuss your options and expectations.

Subglandular vs submuscular implant for me?

Thank you for the question. There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”.    I will try to outline some of the differences here;  you may find the attached link helpful as well.



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 these sub muscular position.    


Patients who are considering breast augmentation/lifting surgery should understand that this combination surgery is significantly more complex than either one of the procedures done separately. In other words, the combination breast augmentation / mastopexy surgery differs from breast augmentation surgery alone in that it carries increased risk compared to either breast augmentation or mastopexy surgery performed separately.



Furthermore, the potential need for revisionary surgery is increased with breast augmentation / mastopexy surgery done at the same time.  This revisionary rate may be as high (or higher) than 20%. Patients should be aware of this higher revisionary rate;  obviously, the need for additional surgery, time off work/life  considerations,  and additional expenses  our “factors” that should be considered before undergoing the initial operation.  



Personally, I find that the breast augmentation/lifting procedure to be one of the most challenging  of the breast operations I perform, even compared to somewhat complex revisionary breast surgery. On the one hand,  when performing breast augmentation/lifting surgery we are increasing the breast  size with breast implants;  on the other hand, we are reducing the breast “envelope” in order to achieve the breast lift. These two “forces” must be balanced as perfectly as possible in order to achieve the desired results. Removing too much skin/ breast tissue is problematic;  removing too little breast skin/tissue can also be problematic.  Remember also that patients presenting for breast lifting surgery and general have lost some skin elasticity/thickness making potential incision line healing problems and/or recurrent drooping/sagging important concerns to communicate.  



The analogy I use in my practice is that  of a thinned out balloon,  being expanded with additional air, while at the same time removing some of the balloons rubber surface.  I hope that this analogy helps patients understand some of the issues at hand when performing the combination breast augmentation/lifing operation.



To achieve  a surgical result where the breast implant and breast tissue “come together” and behave like a single breast is one of my goals but can be difficult to achieve.  Essentially, we are trying to create a breast implant/breast tissue interface that feels and behaves as naturally ( as a single unit)  as possible. Generally speaking, making sure that the breast implant has some sub muscular and some sub glandular component ( dual plane)  and tailoring the overlying skin/subcutaneous tissue/breast tissue as precisely as possible over the underlying breast implant is key.



Despite these efforts, breast implants are after all a foreign body that don't necessarily stay where we wish they would;  therefore, breast implant related problems such as positioning ( too high, too low, lateral displacement etc.) can occur  and may be a reason for returning to the operating room for revisionary breast surgery. I use a “tailor tacking” technique that allows a determination of what breast implant should be used to SAFELY produce the results the patient is looking for. This technique involves use of a temporary sizer and temporary “closure” of the overlying breast skin over the sizer.  The use of the tailor tacking technique is very helpful.  Breast lifting involves removal of skin ( and tightening of the breast skin envelope)  while breast augmentation involves expansion of the breast skin envelope. These 2 forces are counteracting each other.   Again, despite these efforts, breast implant and/or tissue/skin complications may arise causing minor or significant complications.  



Generally speaking, it is difficult to achieve the “perfect” result with breast augmentation/lifting surgery, despite best efforts.  Patients should be aware of the complexity of this combination procedure, achieve REALISTIC EXPECTATIONS prior to proceeding, and understand that additional surgery ( along with the additional recovery time, stress, expenses etc) may be necessary in the short or long-term. Patients should understand that the results of the procedure will not necessarily match aesthetically the results of patients who have undergone breast augmentation surgery only.



For example, some patients who wish to maintain long-term superior pole volume/"roundness" may find that this result is not achieved after the initial breast augmentation/lifting operation.  An additional operation, possibly involving capsulorrhaphy, may be necessary to achieve the patient's longer-term goals ( with superior pole volume/roundness).  It is helpful if patients understand that this breast implant capsule used to provide the support for the breast implant is not present during the initial breast augmentation/lifting operation.  The capsule (layer of scar tissue) forms around the breast implant and may be a good source of supportive tissue during revisionary breast surgery,  Including correction of breast implant displacement/malposition problems ( such as bottoming out, symmastia,  lateral displacement etc).  



Potential risks associated with breast augmentation/lifting surgery include infection, bleeding, incision line healing problems, loss/change of nipple/areola complex sensation, and blood flow related issues  to causing skin or tissue necrosis.   Poor scarring,  pigment changes, areola/nipple asymmetry etc. are also potential problems. Again, patients may experience implant related problems such as encapsulation, leakage, displacement problems ( too high, bottoming out, lateral displacement, asymmetric positioning etc.), rippling/palpability of breast implants etc.  Patients may also be dissatisfied with breast size, shape, and/or how the  breast implants and overlying breast tissues “interface” with one another.    Occasionally, a breast implant may even have to be removed and the patient will generally be “implant free” for several months at least.  Obviously, this situation can be quite physically, emotionally, and psychosocially stressful to the patient involved.




Although practices will vary, in my practice, given your anatomic starting point, I would likely recommend a two-stage procedure:  the first stage would involve breast lifting surgery, the second stage breast augmentation surgery.  You will find a lot of information about the breast augmentation/lifting procedure on this website and on the attached link as well.



Best wishes for an outcome that you will be very pleased with.

Subglandular vs submuscular implant for me?

I would recommend a subglandular approach to your lift with implants. Behind the muscle is a more natural look and given the addition of the lift, will result in the best surgery outcome. 

Richard Zienowicz, MD
Providence Plastic Surgeon
4.8 out of 5 stars 45 reviews

Choosing implant placement

Thank you for asking about your breast lift and augmentation.

  • Since you are having a lift, it is safer to have the implants behind the muscle -
  • It reduces the risk of infection.
  • Generally implants are smaller than 500 cc when a lift is done at the same time -
  • Otherwise the implants can make it hard to heal and cause infection.
  • If you definitely want 500 cc implants, I suggest you consider having the lift now and in six months having the implants.
  • Always see a Board Certified Plastic Surgeon. Best wishes  - Elizabeth Morgan MD PHD FACS

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.