Breast Augmentation for Body Builders - Above the Muscle?

I regularly perform breast augmentation surgery for patients who participate in body building, fitness and figure competitions. The link to my breast augmentation before and after gallery includes many competitive athletes. While many are initially concerned about sub-pectoral placement and the potential for distortion of the appearance of augmented breasts when the pec major contracts, I am absolutely confident that the aesthetic outcome for these patients will be far superior with implants placed under the muscle.
A pre-pectoral implant in a slender patient, especially one with well-developed muscles, looks just as you imagine it would: like a foreign object, not like a natural-appearing breast. The muscle does not have to contract for a pre-pectoral implant to look unnatural in this group of patients - it looks unnatural every minute of the day.
Achieving the ideal aesthetic position for a sub-pectoral implant requires release of part of the inferior origin of the muscle from the chest wall. I perform the minimal release of the origin of the pec major that is required to get the implant in an ideal position vertically, but also weaken the origin in the area where muscle contraction tends to displace an implant. As a result the vast majority of patients have little to no distortion of their breast appearance when the pec major muscles are tensed. Patients also do not experience any loss of function, strength or range of motion from release of this very limited part of the pec major origin. Many patients have indicated that their natural (but augmented) breast appearance has provided a significant advantage for them in competitions. My gallery of before and after photos include images of women who participate in fitness competitions.

Web reference: http://www.michaellawmd.com/gallery/breastaug1.html

Rachel, you have asked a very good question, to which there is no perfect answer. While there is always a trade-off in any surgery, the significant factors in body builders are 1) low body fat 2) desire to show good pec shape, size and definition.

Because of these considerations, I usually recommend leaving the Pec alone, and accepting the tradeoffs of being above the muscle in a thin person. Specifically, these are visibility of  the implants and visible rippling of the implants. This is decidedly worse with saline implants, so I would definitely recommend only silicone gel implants. And even these are not without wrinkle potential. In terms of implant visibility, this also depends a lot on the size of the implants. The bigger they are, the more likely they are to be seen and appear un-natural. Submuscular implants in body-builders are problematic because of the weird look when the muscles tighten. If you want pectoral augmentation, then go sub-pectoral. If you want breast augmentation, then go sub-fascial (above the muscle).

For very athletic women, as you are, I recommend implant placement above the muscle, but this results in less tissue for coverage of the implant, and with time, you may develop quite noticeable rippling of the implant beneath the skin and breast tissue.  A better choice for your implant above the muscle would be silicone, which has a lesser tendency for visible rippling. 

Since you are having the implant placed above the muscle, you may want to consider gel implants since they will have a more natural feel and don't show visible rippling under the skin as much.

Hello,

As a very good rule of thumb, saline implants should be placed under the muscle, especially if there is very little breast tissue/low percentage body fat.  Breast augmentation performed in the subfascial or subglandular plane (on top of the muscle) is ideally performed with a silicone implant and on patients with at least a 2cm pinch test thickness of the breast tissue.

All the best,

Dr Repta

Web reference: http://aaaplasticsurgery.com

Unfortunately, this is a compromise operation. You will have to accept some of the disadvantages that are naturally a part of the operation and some of those are emphasized by the fact that bodybuilders in general have a very low percentage body fat which makes visibility of the implant much more likely. This is true whether the implant is placed under the muscle or over the muscle. One issue to consider is size. Going too large will not only give a more unnatural appearance it will increase the chance of implant visibility meaning a greater chance of visible rippling and wrinkling. A more conservative size implant will look more natural and that will have less of the chance of visible rippling and wrinkling. A more conservative size implant will also keep you looking in proportion and more athletic. With regard to this issue the silicone implant is preferable because in general it not only feels more natural but it looks more natural because there is less of the chance of rippling and wrinkling compared to saline implants.

The next issue to consider is whether to put the implants under the muscle or over the muscle. There are disadvantages to each of these choices in bodybuilders. Over the muscle or more accurately, sub glandular, results in less soft tissue coverage which could increase the chance of being able to see the implant. This means that rippling will be more visible.

Unfortunately, placing the implant under the muscle increases the chance of movement of the implant with contraction of the pectoralis muscle, which in many cases is undesirable. It can be difficult to predict how much movement of the implant will be present, but in all likelihood, there will be some. So you need to choose which of those problems you want to try to avoid, and which of those problems will be acceptable to you if they are present after the surgery.

I would recommend silicone gel implants and leave up to you whether he would prefer over the muscle, sub glandular or under the muscle, sub muscular given the issues noted above.

There are significant advantages when breast implants are placed beneath the pectoralis muscle. For this reason, the vast majority of breast implants are placed in this location. Under rare circumstances, it’s appropriate to place breast implants on top of the muscles.

One of these circumstances occurs when breast augmentation is performed on patients who are body builders. These patients often have large, thick pectoralis muscles. These muscles flatten the implants and prevent the implants from having definition. In addition, contraction of these muscles can cause distortion of the implants. When implants are placed on top of the muscles these problems are avoided.

It’s important to realize that each patient’s situation is unique and that decisions regarding implant placement involves a series of tradeoffs. For body builders, subglanduler placement is definitely a consideration and should be discussed with your plastic surgeon. Your plastic surgeon should be able to determine which option is best for you.

In my experience competitive body builders generally choose subglandular or subfascial breast augmentation; however, an above the muscle pocket can be associated with a higher risk of wrinkling and capsular contracture. 

In order to minimize the risk of wrinkling when using a pocket above the muscle, the surgeon must carefully choose patients who would be at low risk and use an implant to minimize the risk. Patients need adequate pre-pectoral soft tissue coverage (as determined at the examination) in order to be good candidates for a subglandular or subfascial pocket. Although it may seem otherwise, the pre-pectoral soft tissue coverage can and often is adequate even in bodybuilders. The type of implant impacts the risk of wrinkling. I would recommend a silicone implant with a highly cohesive gel; I would not recommend a saline implant. 

Textured implants are associated with a lower capsular contracture rate particularly when the implant is placed above the muscle. 

So my implant recommendation for an above muscle pocket would be highly cohesive silicone gel with a textured shell. 

If you were to decide that the risks of an above the muscle pocket are too great to accept then you would consider the pros and cons of a dual plane (under the muscle pocket). Implant animation is associated with the dual plane pocket - the implant can move high up on the chest wall when the pectorals muscle is flexed. Also there is some loss of pectoralis major function. This loss is insignificant in all but high performance athletes - you may well be in this group. 

Consult with a board certified plastic surgeon with significant experiance in aeshtetic breast surgery. I would suggest you visit with a surgeon who is comfortable using pockets above and below the muscle as well as being well versed in using the different implants available currently. The link below will take you to a page on my website that lists the pros and cons of the various options in breast augmentation. 

Web reference: http://www.cosmeticsurgeonboston.com/cosmetic-surgery/breast-augmentation-options.cfm

There are trade-offs for both types of implants and positioning. For you I would recommend silicone implants above the muscle (saline is likely to show rippling and will not be as soft given your low body fat and placement above the muscle). Discuss your options with a board certified plastic surgeon to decide which implant and position is best for you. 

I would recommend silicone implants on top of the muscle, as I feel silicone looks/feels more natural and is less likely to wrinkle/ripple.   In terms of size, the bigger the implants, the higher the risk of complications.  In order to make an accurate size recommendation, I would need to assess your chest wall and breast mound measurements and characteristics.  Unfortunately, there is not a general rule of thumb or objective criteria to implant selection.

Your plastic surgeon will perform several measurements of your chest wall and breast anatomy and determine a range of implants that both fit your chest wall and reach your desired goals.
The next step is to try on this range of implants in the office with your doctor.   The key to this success is showing your surgeon the body proportion you desire with a bra sizer and allowing your surgeon to guide you to the right implant.   It will be much easier to communicate in implant cc's than cup size when determining the appropriate implant for you.
I wish you a safe recovery and fantastic result.
Dr. Gill

Web reference: http://www.drpaulgill.com