Can I consider subglandular (overs) with this very small, low profile implant? (Photo)

Question

I have low set large B cups. No big increase in size desired, just want to fill them out a bit with silicone implants + fix the convex effect in my upper pole! Different surgeons have advised sub musc + sub gland, all w/small implants. I am a masseuse: animation deformity during work would be embarrassing. I would love for them to bounce/ 'behave' like naturals, & not migrate outwards/downwards. CC risk + the effects of gravity bother me, but does the small size mean I can get away with it?

Michael Constantin Gartner, DO · Answer

in general I always prefer submuscular implants over subglandular implants for a few reasons. The implants in the submuscular position stay in position better, in the sub glandular position you were lying on your skin and tissues which gets thinner as you get older so there's a greater risk that they can drop much quicker. This also increases the risk of wrinkling or rippling visibly noticing it. The risk also of capsular contraction is much higher 20-25% in the sub glandular position versus 4% in some muscular position.I would recommend you seek a board certified a plastic surgeon by the American Board of plastic surgery performs many breast augmentation's. Best of luck

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:

·      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

when compared to subpectoral augmentation.

·      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.

Subpectoral Augmentation:

·      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.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other.  As always, your board certified plastic surgeon can help guide you in your decision making process.

Luis E. Redondo, MD · Answer

Yes you can have your implant over the muscle, I would be completely against a low profile for you, go for moderate 200- 250cc Saline, microtexturized implants. Round will be OKBest of luck,

Levi J. Young, MD · Answer

I think going over the muscle is a great idea based on your description.  There would be less discomfort and faster recovery and no possibility of animation defect.  A conservative size of implant would get the fullness and not look too "fake".  However, do realize that the addition of the implant will definitely add volume and you will as a result be larger.  The end cup size being the volume of breast tissue you have plus the volume of the implant.  I think you're a great candidate based on the photos.  Best wishes!!!

Tom J. Pousti, MD · Answer

Thank you for the question and the good quality photographs.  Based on the quality of the photographs and the detailed nature of your post/presentation, I suspect you already know the pros/cons associated with breast implant positioning.  Nevertheless,  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)  they can be seen with breast implants placed in these sub muscular position.    Best wishes with your upcoming surgery.

Matthew H. Steele, MD · Answer

Thank you for your question and photos.  From what I can see, you appear to have adequate pinch thickness to accommodate subglandular implants.  Most surgeons recommend at least 2cm of pinch thickness in the upper pole.  Also, with the lower position of your breasts on your chest, a subglandular placement will look better than subpectoral as you would be at risk for a snoopy deformity (double contour deformity).  I would recommend a lower profile to try to match your breast width and a textured implant to reduce the risk of capsule contracture.  Good luck.

Brooke R. Seckel, MD, FACS (retired) · Answer

You appear to have adequate superior pole pinch thickness for subglandular breast implants.  He needs to understand the increased risk for capsular contracture and that with time subglandular implants often become more visible.  My preference is always submuscular whenever possible and with the amount of glandular ptosis that you have a dual plane augmentation would be preferred.  However if you're willing to take the risks of capsule invisibility of implant then the decision is yours.

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