My surgeon keeps changing his mind about going under the muscle vs going over the muscle. Which you would perform? (Photo)

Prior to my mastopexy, my surgeon discussed inserting implants under the muscle. He then discussed going over the muscle because I have enough breast tissue to disguise the implant and that this may achieve a more natural look/feel and a closer cleavage. Recently he decided under the muscle due to concern of damaging my tissues and affecting blood supply to my breasts. My worry is that my muscles may be quite far apart leaving me with a large gap between my breasts which I really don't want.

Doctor Answers 4

I would recommend muscular (dual plane) augmentation...

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Thank you for the question.  Congratulations on having undergone the mastopexy procedure. 

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).  Cosmetically speaking, I think that breast implant placement in the sub glandular position (over the shorter or longer term) tend to be associated with more problems with visibility (rippling) or palpability.  Basically, the more coverage we have overlying breast implants, the better the long-term look/feel seems to be. 

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.    


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

Under or Over the Muscle?

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Hello there.  I think that you will find that there is no specific answer, there are pros and cons for both.  It is always difficult to make an assessment on photographs, but my view would be to go on top of the muscle, although I would have a conversation outlining the potential benefits and risks.

I am not sure if you are going to get a definitive answer, I would trust in your surgeon and have a discussion with him or her about it to try to come to a balanced decision and go with that.

Over or under the muscle

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The bottom line is that there is no correct answer here.  You do have enough tissue to hide your implants well in the short term and, if you are using a relatively modest implant, they should behave very well in the long term too.  Your surgeon is probably finding it difficult to decide because you are a good candidate for both techniques. Whilst this undoubtedly  is a little confusing for you, it is a good thing and I wouldn't worry too much about it. My opinion, I would be using a relatively low profile implant in a subglandular plane unless you are going over, say, 300cc.  I have found 3-D imaging to be invaluable in giving people an idea of the cosmetic differences between the two techniques, so I hope the link gives you some helpful information. Best of luck

Over or under the muscle?

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Thank you for your question and photos.  Congratulations on your nice result.   From what I can see you would probably do fine with either approach.   An in-person exam would be helpful to judge your tissue thickness.  A submuscular approach will typically give you a more natural result with a lower risk of capsule contracture.  You are right that widely spaced muscles can influence your cleavage, however, implants placed on top of the muscle could have a higher risk of a uniboob (symmastia).  I would discuss the pros and cons of each approach with your surgeon.  Good luck.  

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