Which is better? Over or under the muscle for a BA with uplift?

I have 34 D breasts, I have lost 3 stone and saggy boobs, 1 25 from the collar bone the other 27 so a lift is needed. I am 5'6 and wear dress size 10/12 and a broad back. I would like to be a similar size but have the fullness at the top of the breast. Can you suggest a cc and whether over or under the muscle is best please? Thank you

Doctor Answers 4

There is no better - under and over the muscle both have a place

Dear Alio,

Patients will often ask which is better - under or over the muscle and the answer is that neither is better.  If one of them was better, we would always do it that way.  There are pros and cons of both and you need to balance the risks and benefits to try to come to an opinion on what might be right for you.

I would be wary about asking for an opinion about what cc would be best for you as you need to choose an implant that will fit your frame - it is not just the volume that you need to consider.  I have put a link to a video where I talk about this.  There is also a webinar that you can access through my website on the breast enlargement page.

I would recommend that you have a consultation with a plastic surgeon - look for the letters FRCS(Plast) after their name, the BAAPS and BAPRAS websites have a list of members.  All the best.

Which is better? Over or under the muscle for a BA with uplift?

Thank you for your question.

Especially when a breast lift is combined with breast implants, in my opinion it is much safer to place the implant underneath the chest muscle to protect the blood supply to the nipple areola.  During the course of a breast lift the blood supply to the nipple areola is diminished and pressure from an implant on top of the muscle or an implant that is too big can damage the blood supply and result in loss of the areola and nipple.

Size of the breast implant will depend upon a measurement of the base width of your breasts which are surgeon should do.  Personally when I combined breast implants with a lift I'm reluctant to use implants larger than 350 cc.

For more information on combining breast lift with implants please read the link below:

Which is better? Over or under the muscle for a breast augmentation with uplift?

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.

Generally speaking, patients undergoing this combination operation should understand that it is significantly more complex than breast augmentation surgery only and that it is associated with will a significantly higher risk of complications and need for additional surgery.  Again, it will be important that you educate yourself regarding the pros/cons/risks/complications associated with breast augmentation/lifting surgery.

As you likely know, there will be limits as to how large of a breast implant can be utilized safely during the procedure.  Remember, that during breast lifting surgery, some skin is removed, thereby limiting the "space" available for breast implants. On the one hand, breast augmentation surgery is expanding the breast skin “envelope” while breast lifting is (by definition) tightening up the breast skin envelope. These 2 forces are counteracting each other. Therefore, it becomes important to remove the appropriate amount of breast skin and to use the appropriate size/profile of breast implants to balance these 2 forces appropriately and to allow for achievement of the patient's goals while minimizing risks of complications. 

Generally speaking, the best online advice I can give to ladies who are considering breast augmentation/lifting surgery ( regarding breast implant size/profile selection) is:

1. Concentrate on choosing your plastic surgeon carefully. Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you are looking for. ***Ask to see lots of examples of his/her work.

2. Have a full discussion and communication regarding your desired goals with your plastic surgeon. This communication will be critical in determining breast implant size/type/profile will most likely help achieve your goals. 

In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. For example, I have found that the use of words such as “natural” or "C or D cup" etc means different things to different people and therefore prove unhelpful.

Also, as you know, cup size varies depending on him who makes the bra; therefore, discussing desired cup size may also be inaccurate. Again, the use of computer imaging has been very helpful during the communication process, in our practice.

3. Once you feel you have communicated your goals clearly, allow your plastic surgeon to use his/her years of experience/judgment to choose the breast implant size/profile that will best meet your goals. Again, in my practice, this decision is usually made during surgery, after the use of temporary intraoperative sizers.

I hope this (and the attached link, dedicated to breast augmentation/lifting surgery concerns) helps. Best wishes for an outcome that you will be very pleased with.

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Hello and thank you for your question. There are several advantages and disadvantages to over vs under the muscle.  Under the muscle has the advantage of lower capsular contracture rates, less risk of rippling, and better visualization with future mammograms.  Most patients say that under the muscle also has a more natural look and feel.  The size, shape, and profile of the implant is based on your desired breast size/shape, your chest wall measurements, and soft tissue quality.  This decision should be based on a detailed discussion with equal input from both you and your surgeon.   Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.   The most important aspect is to find a surgeon you are comfortable with. I recommend that you seek consultation with a qualified board-certified plastic surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Richard G. Reish, MD
New York Plastic Surgeon
5.0 out of 5 stars 67 reviews

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.