I’m booked in to have 550cc HP over the muscle but am concerned about sagging in the future. Would under/dual plane be better?

Question

My implant size is 550cc silicone round. My main concern is that I do train a lot in the gym, I’m worried about this having an impact on implant shape etc if I go under the muscle. What is (in your opinion) my best option for implant placement? With the least risks for the future? (Current breast size in photos) Thanks in advance!

Daniel Barrett, MD · Answer

Dear Sarahtonin_x,
I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Kenneth Hughes, MD · Answer

I think that most plastic surgeons would agree that a breast augmentation result where the implant is placed under the muscle (dual plane) tends to have better longevity than a breast implant placed over the muscle.  For these patients in whom the living is made by athletic performance, the implant can be placed above the muscle.  Other patients will be happier long term with submuscular placement.
Kenneth Hughes, MD, ABPS Board Certified Plastic Surgeon
Los Angeles, CA

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.
 Subglandular Augmentation (“overs”): 
Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster.Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling when compared to subpectoral augmentation.Subglandular implants can also create the illusion of improved cleavage by preferential over-dissection of the central/medial pocket allowing the implants to be forced more to the midline. There is no limiting muscle as there is in a submuscular augmentation. 
Subpectoral Augmentation/Sub-muscular/Dual Plane (“unders”): 
Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.Subpectoral implants have a lower rate of capsular contracture.Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.In my practice, the vast majority of patients will have the implants placed submuscular for all the reasons listed above.With regards to your specific question, there are a number of issues to consider. Submuscular augmentation does result in a real but negligible (for most) loss of strength. Animation can be a concern as well. Submuscular shape is different but for most preferable to subglandular (see above). However, the overall risks are lower when implants are placed deep to the muscle. It is for this reason most patients prefer submuscular augmentation.
As always, discuss your concerns with a board certified plastic surgeon (ABPS).
Donovan Rosas MD
Board Certified by the American Board of Plastic Surgery
Member: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons
RealSelf Top 100
RealSelf Hall of Fame

Tom J. Pousti, MD · Answer

Thank you for the question. 
 It is extremely common to receive different opinions from different plastic surgeons about the best way to proceed. Each plastic surgeon may have his/her opinion that is based on their specific/unique education, experience, and personal preferences. Their opinions may also be shaped by unfavorable results they have encountered in their practices.   
There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”.   I think it is in the best interests of most patients (including athletes) 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 the sub muscular position.  
 Best wishes with your upcoming surgery.

Richard Baxter, MD · Answer

Over muscle implants will not cause animation deformity but may look unnatural when they are large and the patient is thin, as weight trainers often are. Under muscle placement with the dual plane will result in weakening of the pectoral muscles and often distortion with muscle activity. Consider the split muscle approach instead (also called muscle splitting biplane.)

I’m booked in to have 550cc HP over the muscle but am concerned about sagging in the future. Would under/dual plane be better?

Answers (6)

Answer: Under or over pectoralis major muscle best for breast augmentation surgery?

Answer: Under or over pectoralis major muscle best for breast augmentation surgery?

Answer: Caution with under muscle implants for weight training

Answer: Caution with under muscle implants for weight training

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I’m booked in to have 550cc HP over the muscle but am concerned about sagging in the future. Would under/dual plane be better?

Answers (6)

Answer: Under or over pectoralis major muscle best for breast augmentation surgery?

Answer: Under or over pectoralis major muscle best for breast augmentation surgery?

Answer: Caution with under muscle implants for weight training

Answer: Caution with under muscle implants for weight training

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Recommended reading

Everything you need to know about Breast Implants

Our mission is to create a world where every investment in modern beauty is Worth It.