Over the muscle, under the muscle is a very complex issue. Every patient is different and must be evaluated case by case. A hands on thorough examination is critical in choosing the proper operation.
There is a lot of bad advice available. Beware of the inexperienced when you hear:
"Definitely gives the breast a more natural look if the implant is under the muscle."
" Under the muscle drastically decreases the risk of capsular contracture."
" Absolutely confident that the aesthetic outcome for these patients will be far superior with implants placed under the muscle.
"Placing the breast implant under the muscle gives them much better long term support."
"Gummy Bear implants are superior to silicone memory gel implants".
"if the implant is under the muscle mammograms - telling them you have implants will prompt them to take one extra view. With this extra view, the detection of cancer is the same as if you did not have implants."
There are patients who's activity and anatomy make them unsuitable for sub-muscular placement. (See Pole Dancer Deformity) They are better off having no implants at all, than placing implants under the muscle.
Patients who insist on having implants under the muscle for a better mammogram and have anatomy that will result in a cosmetically inferior result are advised; we will not trade an ugly breast in exchange for a better mammogram. The surgeon's job is to give you the most natural looking and feeling breast possible with the tissue he has to work with.
If your anatomy is not suitable for sub-muscular implants, and you want the best mammogram, DO NOT HAVE ANY IMPLANTS AT ALL FOR THE BEST MAMMOGRAM.
Best wishes. Knowledge is power Luis F. Villar MD FACS