Breast Augmentation: Cost, Reviews, Photos

Implant placement under or over the muscle

You have a normal figure with good skin envelopes. An over the muscle approach is the only one you should consider.

Under the muscle implants are isolated from your natural breast tissue leading to the possibility of separation of volumes.

This causes a funny looking double contour after a few years with the implant held up high by the muscle and the breast sagging below.

The only time I would even consider for a minute an under the muscle placement is for a women whose bones i can read across her chest.

Gel implants are much softer and more natural than saline implants and are very well tolerated under the breast even in slender women. Size should be determined by what is proportionate to your figure. I use temporary sizers in the OR so I can choose the exact implant for each patient. (Daniel Greenwald, MD, )

Dual plane larger implant silicone. Best of both placements. Subglandular does have a slightly higher capsular contracture rate and more issues long term. Dual plane does give a slight lifting to the breast.

You did not state what size bra you want to be. Based on your pictures I would rec 400 cc High profile to get you to a full c small d. (William Alan Dulin, MD, Dallas Plastic Surgeon)

There is no consensus

So now you have 4 different doctors and all different opinions. For someone with what I see in the photos, I would put smooth silicone over the muscle to fill you out.

The size implant depends on how big you want to be and your current height and weight and breast diameter. There is no definitive proof that sub muscular is better than sub glandular for silicone implants.

I have been doing this for over 30 years and have had to deal with many different fads, now, I have found that I seem to get the best results by putting silicone under the gland. That is where your breast is and where it belongs.

Breasts are not under the muscle, so why put implants there. Pick a surgeon you like and who listens to you and explains their rationale. (William B. Rosenblatt, MD, New York Plastic Surgeon)

Placing breast implants under the muscle has significant advantages such as reduction of capsular contracture, smoother upper breast shape with better concealment of the implant, less thinning of the breast over time. The advantages are so great that 80% of breast implants are placed in a submuscular location, by the majority of surgeons. We don’t just do this out of habit. There are reasons for subglandular augmentation though your photos suggest that you should be one of the 80%. (Peter E. Johnson, MD, Chicago Plastic Surgeon)

From your appearance in the photographs, you would likely be a good candidate for dual-plane placement of your implants. From your pictures, it appears that your breasts are too low for a traditional submuscular placement, and the implants may sit too high. In order to keep a natural appearance and still maintain muscle coverage at least on the upper part of the breast, a dual plane approach would probably suit your situation best.

This is partially under the muscle (upper part of breast) and partially over (lower part of breast) From a pure appearance perspective a subglandular or partial submuscular(dual-plane) placement would probably be best, but as alluded to before there are potential disadvantages of subglandular placement. There are disadvantages of submuscular as well, such as potential for the muscle to move the implant.

Part of the discussion you need to have with your plastic surgeon is exactly how you expect your breasts to look, particularly how high on your chest, how much fullness of the lower breast area etc, how close together etc as the decision on placement will affect these issues. There is not one way to do breast augmentation, there are pros and cons of each approach. A lift might enter into the discussion if you really want the breasts elevated as much as possible, but then the tradeoff is additional scarring and surgical risk. (Jeffrey Hartog, MD, Orlando Plastic Surgeon)

I think from looking at your pictures that you should get a nice result from breast augmentation either subglandular or submuscular. It also appears that implants in the 300 cc range should fit you well.

If you do choose to go submuscular, remember that it will take about three months for the muscles to relax so at first your implants will appear to be too high on your chest. They will come down in time. Diferent plastic surgeons may have difference preference on submuscular or subglandular. Ofter, either technique will work equally well. (James Tang, MD, Houston Plastic Surgeon)

Whenever possible, it is better to place breast implants under the muscle.

They look and feel more natural, and there is less chance for capsular fibrosis and hardness.

Even more importantly, mammogram readings are more accurate, because there is a natural barrier between the capsule that forms around the implant and the actual breast tissue.

I think the size range you are considering is a good one for your body.

You appear to have a little sag on the left breast, but you can always determine whether you want to address that after your augmentation.

(The symmetry may improve, but there will be more scarring). Both nipples are well above the inframammary fold line, which is good. I think you could get a very nice result with submuscular breast augmentation, using silicone gel-filled implants. (Diane L. Gerber, MD (retired), Chicago Plastic Surgeon)

Submuscular breast implant placement is better than subglandular

The advantages of soft tissue coverage, breast contour, reduced capsular contracture rates and ease of mammographic interpretation make submuscular augmentation the implant position that I recommend in almost everybody. (Scott C. Sattler, MD, FACS, Buffalo Plastic Surgeon)

You should be aware that an augmentation alone will not correct these differences. Since you desire a relatively small implant and appear to have adequate soft tissue coverage, I feel a subfascial augmentation is a reasonable approach. I rarely place an implant in a pure subglandular pocket. The advantages are less pain, faster recuperation, sooner achievement of the final result, no muscle distortion, and less implant displacement. The only disadvantages would be a slightly higher risk of contracture and it may be more difficult to see all of the breast tissue on mammogram. As you can see from the responders there is no absolute consensus. Good luck! With either approach you will be extremely happy. (Todd B. Koch, MD, Dallas Plastic Surgeon)

All natural breasts develop subglandularly. No God given breasts are submuscular. So why should Plastic surgery breasts ever be in defiance with natural body construction? Think about it. Subglandular implants give superior cleavage and move with natural breasts and fit clothes naturally and are obvious choice for someone who wants as natural an outcome as possible.

Submuscular implants have wide cleavage, move with muscle contraction independent of overlying breast and thus give somewhat unnatural behavioral outcome. In your case you also have some sagging. Submuscular implants will give you a double bubble effect unless you also had a breast lift. Subglandular implant will blend with your shape and you can get by without breast lift. In summary my recommendation to you is to have your augmentation with subglandular silicone gel implant. (Vasdev Rai, MD, Seattle Plastic Surgeon)

Since subglandular implants don’t lift the breast, are worse for mammograms, have more capsular contractures, look edgier in many patients, I see no compleeing reason not to go submuscular in virtually everybody. If you need a lift, an implant will not accomplish that for you, only a lift will. Using words like “perky” is very confusing when they are mixed with words like “natural.” Best to show graphically what the “look” is you want then try to figure out based on an exam what implant will get close to that look. (Richard P. Rand, MD, FACS)

Implant location over or under the muscle is based on the amount of soft tissue present over the muscle in the upper part of the breast. If you can pinch about an inch of tissue in the upper part of the breast, implants may the be placed over the muscle. Generally speaking, for slim individuals with small breasts the preferred implant location is below the muscle to avoid that fake round look and to avoid visible rippling. (Andrew P. Giacobbe, MD, Buffalo Plastic Surgeon)

The placement of breast implants can be either above or below the muscle.

The majority of plastic surgeons insert the implants under the muscle.

In my practice I evaluate the patients chest prior to making a decision.

If a patient is very flat with very little breast tissue I, generally, recommend going below the muscle because it would lead to a more natural result because of the added cushioning of the muscle.

In patients who do have breast tissue you can go either way, although there are still some advantages to going below the muscle such as decreased capsule formation.

In your particular case I would probably go below the muscle because of hollowness in the upper pole of the breasts. I also would probably suggest doing a breast lift through an incision around the areola. (George Lefkovits, MD, New York Plastic Surgeon)

Each surgeon does things a bit differently. I prefer in most patients to place them submuscularly. This is because it adds another layer of soft tissue to cover the implant especially in the upper pole. As for volume, it depends upon what you want and what your anatomy dictates. (Steven Wallach, MD, Manhattan Plastic Surgeon)

It looks like about half the surgeons say go above the muscle and half say put the implant under the muscle including those that say do either one and you will be happy. I am sure you are no further along in making a decision than you were before posting your question and photos or seeing the surgeon presumably in your hometown.

It might be better to ask what approach will give me the most natural symmetric look and then what size would make me happy. The photos show a vertically elongated triangle between the sternal notch and nipples. The left nipple is lower and further from the midline relative to the right nipple. The majority of the breast tissue is in the lower half of the breasts and there does not appear to be any ptosis. The only thing you can definitely say from the photos is you will need a skin procedure to make the nipples more symmetric.

If you just insert the implants the asymmetry will not be resolved and will likely be magnified. The next decision is under the gland vs. under the muscle and then implant size/shape and then surgical approach. A natural look means the edges of the implant are covered by tissue so that you do not have an abrupt edge of implant visible from the outside.

That is controlled by placing an implant with a base diameter less than breast base diameter and increasing the amount of tissue in the upper half (putting the implant under the muscle) when the tissue coverage is thin. Some surgeons say that the last point does not matter if silicone gel is used but I have not found that to be the case and found it better to just put the implant under the muscle in appropriate patients than have to do a second procedure because the implant edge is too visible.

You will eventually have to go with the surgeon you feel most comfortable with. Who can answer your questions to your satisfaction and who has the most logical reasons for his/her approach.

My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship. (Aaron Stone, MD, Los Angeles Plastic Surgeon)

You are an excellent candidate for partial retropectoral (under muscle) breast augmentation. Placing the implant under the muscle would help reduce risk of capsule contracture and give a natural upper pole appearance.

The inferior and inferior medial muscle fibers are released so the implant sits low enough and does not ride high, thus providing the proper shape. In this way you get the best treatment possible with the optimal chances at a lovely result. (Louise Ferland, MD, New Orleans Plastic Surgeon)

You will get great result with sub glandular or sub muscular augmentation. The main difference is the long term result.

The concern with sub glandular augmentation is tissue thinning and sagging. I would recommend sub muscular augmentation and for the size 325 high profile . (Kamran Khoobehi, MD, Tampa Plastic Surgeon)

There are definitely many opinions as to which is better, on top of the muscle or under the muscle.

Most docs on here as well as most studies show a lower capsular contracture rate with implants in the submuscular position.

Also, many docs on here have commented that Mammograms are better with implants under the muscle and this also is supported with several studies as well as by the radiologists that I have discussed this with.

Both techniques can provide for you a beautiful result. The issue is which technique is safer for you in the long run for cancer detection, and which is going to provide a better result in the long run with the lowest incidence of capsular contractures?

Since capsular contracture has been one of the most commonly occurring complications since the beginning of breast augmentation, and since detecting breast cancer at an early stage via mammogram can potentially save your life in the future, why not place the implants in the place which is best for both of these issues?

Clearly under the muscle is better and safer. I perform several hundred augmentations per year and stopped placing implants on top of the muscle over 10 years ago. I haven’t had a single patient in whom I couldn’t get as nice of a result under the muscle as over the muscle. (Daniel P. Markmann, MD, Baltimore Plastic Surgeon)

Sub glandular implants do not “lift” the breast, can gave problems with tissue thinning and changes and have a higher rate of contracture.

I see very little reason to go in the sub glandular position and almost entirely use the sub muscular, dual plane position. You will do well with this procedure. (David Nicholas Csikai, MD, Jacksonville Plastic Surgeon)

Submuscular placement has more benefits and less risk of sagging.

I have found that the submuscular location results in:

1. more tissue covering the implant for a more natural look
2. improved mammograms when compared to the subglandular implants and
3. decreased rate of capsular contracture. Plus, subglandular implants often sag over time. (Otto Joseph Placik, MD, Chicago Plastic Surgeon)

Subglandular vs. submuscular placement

Subpectoral placement in a slender patient such as you provides more tissue to camouflage the implant upper edge and to hide any potential wrinkling of the implant. Both of these problems are more severe with saline implants, but can occur in thin patients with silicone gel implants as well.

Other advantages of subpectoral placement are a somewhat lower risk of capsular contracture, maybe more ease of visualization of breast tissue during mammograms, and perhaps less long term stretching of skin and tissues over the years in thinner patients who may be prone to this.

Disadvantages are some greater discomfort during the first few days, and some distortion of the breast when you contract your pectoral muscles, usually only seen when you are unclothed. Add these all together, and the majority of surgeons place the majority of implants in the subpectoral position.

Dual plane approaches are variations in the subpectoral technique which are used for different indications, and I use them in patients who have loose, mobile lower pole tissues that need to be properly “filled out’ by the implant, and in patients with constricted lower poles. Implants will not lift the breast in patients who need a lift, regardless of what plane they are placed in.

I would never place a subglandular implant in a thin-tissued patient with a sagging, overhanging breast hoping that the subglandular implant would “lift” the breast better than a subpectoral implant and avoid the need for a breast lift or mastopexy. It will only make the problem worse in the long run. (Robert M. Grenley, MD, Seattle Plastic Surgeon)