Under Vs over the Muscle for More Natural Results?

Question

I'm currently a big 'A', small 'B' cup, my height is 5'5.5", slim body frame and weigh about 119lbs. I'm 30 and have 2 children who were both breast fed. I would like to be a full 'C' cup, I've recently been to see a consultant who has suggested he will insert 260cc textured Silicone breast implants (High profile) over the muscle. Does this seem ok?

Shahram Salemy, MD, FACS · Answer

In general, most of us would agree that under the muscle is preferred in most cases, but you should know that for the right patient with the right anatomy, you can get a nice result with the implant placed above the muscle as well-- it really just depends on the surgeon's judgement, style and experience, and combining that with what your goals are.
I would speak to at least one or two more plastic surgeons in your area and go with the one you feel the most comfortable with-- this will give you the best chance at a nice result.
Good luck!
 
Dr. Salemy

Lewis Albert Andres, MD · Answer

Hello! Thank you for your question! Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts. Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years. In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance. Your breast width is the most important measurement. Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant. This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape. Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width. Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later. Very slightly less tissue may be visualized with subglandular implants, but not very significant.Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle). Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each. In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome. A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles. Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions. You may want to consider above if you work out quite a bit.  As you see, there are a few factors to decide upon for incision, placement, and implant type/size. Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits. Hope that this helps! Best wishes for a wonderful result!

Jed H. Horowitz, MD, FACS · Answer

Depending on the  implant type and incision, each placement has their benefits. The possible benefits of #submuscular (under the muscle) placement are that it may result in less palpable implants, decreased risk of capsular contracture, and easier to image the breast with a mammogram. Under the muscle placement is recommend for women are are very thin with very little breast tissue. The partial muscle coverage will hide the implant better and help avoid visibility of any implant imperfections such as rippling. The appearance will also look more natural.This #sub-glandular #placement placement (under the breast
tissue in front of the muscle) may allow for a shorter surgery and recovery with less discomfort. This placement can provide a slight “lift.” #Sub-glandular placement can result in more palpable implants, increased risk of capsular contracture and more difficult imaging of the breast with mammogram. This placement is often recommended for those patients with mild breast sag, but do not want a breast lift (mastopexy) and for tubular breast deformity.The #Dual-Plane placement method is a more current technique most often used when there is mild breast sag and the patient does not want a breast lift. The breast tissue and muscle are partially separated to allow the breast tissue to sit in a better position. Dual-plane can be discussed further during the consultation should breast sag be of concern.

Phillip Chang, MD · Answer

Most surgeons would advise against placing breast implants above the muscle.  The opposite is true; most surgeons place breast implants beneath the muscle.  This is performed for three basic reasons:
1.  By placing the implant beneath the muscle, the muscle camouflages the implant to some extent so your breast looks more natural and less circular.
2.  The second reason is that it is easier for a radiologist to read a mammogram when it is below the muscle.
3.  The third reason is that it reduces the complication rate for capsular contracture.
With respect to your consultation, I would suggest a second opinion.  Namely because most surgeons no longer use textured implants routinely. Textured implants were at one time thought to reduce capsular contracture complications. This is generally felt no longer to be true.

Manish H. Shah, MD, FACS · Answer

Dear Dufu,
It is generally agreed that the best long-term results occur with under the muscle placement of breast implants.  The implants are better protected, rates of capsular contracture are typically lower, and if you have saline implants or are very thin, rippling/waviness of the implant is less detectable.  I typically only put implants over the muscle if patient use silicone implants and are extreme athletes (eg. body builders, martial artists, heavy weight lifters, etc.)  The reason for this is that the pectoralis muscles in these women are so strong that they push the implants down and out from the center creating a large gap and breasts that are too low.  Also, if they are in competition gear every time their muscles flex, the implants move unnaturally.  The average woman does not have this concern or goes to the gym and works out like most of us (not super aggressively.)  You seem really tiny, so I would recommend that under the muscle placement be entertained.
Good luck,
Dr. Shah

John Diaz, MD · Answer

Having your implant inserted under the muscle is better for two main reasons.
1. The muscle provides an additional layer of coverage for the implant. This helps make it more difficult to see or feel the edges of the implant.
2. Research has shown that women with implants under the muscle have a lower risk of capsular contracture. This is a condition in which the scar around the implants becomes hard and thick.
One reason to put the implant above the muscle is because some think that it creates a slight lifting effect to the breast.
Another reason to put it above the muscle is to avoid movement of the implant with muscle activity. This can be an issue in women who are very muscular.
Unless you are someone who needs the implant above the muscle for one of the reasons above, you should review your options again with your surgeon. Always explain your concerns. A good surgeon will value your input and take time to carefully explain their recommendations.

David Shafer, MD, FACS · Answer

In most cases, under the muscle gives the best results. The muscle does thin out, but it does not "die." However, the muscle gives an extra layer of your own tissue covering the implants. This makes it even less likely that you will be able to feel the implants.

Dean Fardo, MD · Answer

I would agree with Dr. Jejurikar's response above.
Anatomically speaking, breast implants above the muscle are more "natural", as there is not any breast tissue normally underneath the muscle. However, most surgeons currently prefer submuscular placement. This is a question that comes up often and there are pro's and con's of each approach. One approach is not always better than the other. Both have their places. A thorough consult  should help you determine which approach is best for you. Good luck.

Sam Jejurikar, MD · Answer

Different surgeons have different approaches to breast augmentation, but virtually all of us would agree on a few points:
1) Submuscular implantation of muscle does not cause the muscle to die.  The muscle does thin out and get stretched, but it certainly remains alive.
2) A 260 cc implant will not allow you increase 2 full cup sizes, from an A cup to a full C cup.
3) With the earlier generation textured silicone gel implants, submuscular placement was shown to result in less capsular contracture formation than subglandular placement.
That being said, there are a few circumstances in which subglandular placement has some benefits.  In women with thick chest wall muscles and others who need a significant lift of the nipple and areola, subglandular placement can have advantages over submuscular placement.
My recommendation is to consult with at least 1 or 2 other board-certified plastic surgeons.  The more opinions, the better equipped you'll be to make an informed decision.
Best of luck.

Ricardo A. Meade, MD · Answer

I'm not sure I agree with what you've been told but there are many different opinions in the operation that you're seeking.

	I don't think you'll be a full C cup in 260cc implants, even subglandular. Committing to a cup size can be disappointing. The size may be smaller than you are expecting -- it's not easy to know what you think a full C cup is. I do however think that the size you've been suggested will look great on your body. It is a very tasteful size selection and your ABPS Board Certified plastic surgeon see's that. You should try on that size implant in a bra with a fitted shirt over it (your consultation may have provided that experience). It will appear similar to the end result in clothing.

	The muscle wastes some inferiorly when it covers the implant, but it doesn't die. The fact is that you're pretty thin, so unless you're very muscular it is already a thin muscle and it won't make too much of a difference in soft tissue coverage but above the muscle your risk of capsular contracture is higher. What you are reading is correct, submuscular placement is the most popular placement of an implant due to the best longevity demonstrated on countless clinical studies. The subglandular position was the original placement of implants but after enough experience this positioning was only used under certain circumstances (adequate breast tissue coverage, body builders). Most agree that submuscularly, implants age better.

Under Vs over the Muscle for More Natural Results?

Answers (20)

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