Obviously there is no one "right" place to put a breast implant and not even any agreement among surgeons as to the "best" place. Unlike many surgeons, I feel that in general for most women on top of the muscle gives a more natural appearance. After all, the breast tissue we are trying to increase is above the muscle and I feel an implant above the muscle behaves and moves more naturally than one below it. I also feel that there is a different look for implants placed under the muscle and many of my patients don't like that look. And each surgeon has different experience and facility with different techniques. You need to discuss with your board certified surgeon what your goals are and how best they can be accomplished. You need to be comfortable with the plan that you and your surgeon come up with for you. Good luck.
Is it better to have implant under muscle or over muscle?
Doctor Answers (22)
Breast Implants - Above or Below the Muscle?
This may be a somewhat controversial statement, but in my opinion there currently is really only one acceptable position for breast implants in an elective cosmetic surgery patient: behind the pectoralis major muscle (sub-pectoral augmentation). There are a number of very compelling reasons to place implants behind the pec major, and the most compelling one of all is the fact that radiologists report that the mammographic imaging of breasts for the purpose of breast cancer screening tends to be more easily accomplished when breast implants are sub-pectoral (compared to pre-pectoral, also referred to as the 'sub-mammary' position). An American woman's current lifetime risk of breast cancer is approximately 1 in 8 to 1 in 9, so the issue of breast cancer screening must be taken very seriously. Mammography is by no means a perfect screening study, but it is the standard of care at this point in time. The most sensitive and specific test for breast cancer is a contrast-enhanced MRI scan, and breast implants do not impair breast tissue visualization by MRI.
The next very compelling reason to select sub-pectoral placement is a cosmetic one. Implants placed on top of the pec major tend to stand out in the upper pole of the breast, creating a rounded, convex and distinctly unnatural-appearing breast profile. With implants in a sub-pectoral position, the upper pole of the implant is flattened somewhat by the muscle, helping to create a smooth transition from the area in the upper chest where the breast begins, and a gradual slope towards the nipple that is not excessively rounded or convex. In some patients with a fuller breast volume preoperatively one may get an acceptable appearance with pre-pectoral placement - initially. The problem is that as breasts age, the fatty tissue atrophies and breast tissue thins out, and the area where this is most obvious is in the upper pole and cleavage area. So a pre-pectoral implant that was initially well-concealed may, after a few years, become painfully obvious (including visible implant folds and ripples) in the upper pole.
'Under the muscle' and 'sub-pectoral' are actually somewhat misleading terms, as in most cases the implant is only partially subpectoral. The anatomy of the pectoralis major muscle is such that it is actually just the upper/medial half of the implant that is covered by the muscle, while the lower/lateral half of the implant is submammary. The pectoralis major thus provides an additional layer of tissue to conceal the implant in the most cosmetically significant area of the breast: the cleavage area. This is why saline implants are often easy to feel laterally, as they are covered by breast tissue only in lateral aspect of the breast, and in slender patients who have small breasts preoperatively the implant is often immediately under the skin in this area.
Depends on your body
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Over or under muscle (breast aug) and why?
I generally recommend under the muscle unless the woman is a high performing athlete who needs every fiber of their pecs to perform at a high level. Most us don't fall into that category. Under muscle provides more stable, thicker coverage over implant and has a smaller rate of capsular contracture.
Implant better under or over the muslce
if you are a candidate for under the muscle, I feel that is a better choice as the chances of capsular contracture are less. A little longer to get to the final result versus above the muscle but I feel it is worth it.
Above or Under the Muscle
In the vast majority of cases, I would prefer to place breast implants underneath the muscle for the primary reason that there is a significant increase in capsular contracture or breast hardness with implants on top of the muscle. Submuscular coverage gives more soft tissue coverage of the implants and in many cases makes mammography easier. Yes there may be a bit more post operative pain but with early stretching this can be decreased and long term, I think patients do better. This is my preference, others may have a different approach.
Better To Place Implant Below Muscle In Most Women
It is almost always preferable to place implants below the pectoral muscles if one is seeking a naturally appearing and feeling breast. Silicone implants also provide these qualities more frequently than saline implants. There is a bit more discomfort with submuscular implants but it is usually worth it.
Breast Implants - Above or Below the Muscle?
There is no simple answer to this question and it definitely depends on the individual patient. In general, under the muscle is the more common pocket position in the United States. The benefits include better coverage of the implant at the top and in the cleavage area. Additionally, mammogram is less impaired and reports seem to suggest a lower amount of capsular contracture (hardening around the implant). The drawbacks are that the initial surgery is more painful, there is a certain amount of motion of the breast implant and thus breast with contraction of the muscle and the implant and breast age differently rather than in unison. The above the muscle plane may either be the traditional subglandular or the more recently described subfascial plane. When I put an implant above the muscle, I prefer the subfascial plane which means that the thick coating over the muscle is elevated up with the breast tissue. This gives extra coverage of the implant and towrd the top and inside, I will actually raise up muscle fibers with the dissection to have even additional partial muscle coverage in the area that needs it the most.
Over the muscle or under depends on the patient and the implant
These are the general rules:
Over the muscle is fine in patients with enough subcutaneous fat to hide the implants, and better than subpectoral if the breasts are sagging.
Under the muscle MAY produce a softer result and is better in very thin patients or those preferring saline implants.
There are other factors--family history of breast cancer, textured versus smooth, silicone versus saline. Find a experienced plastic surgeon whom you trust and talk it out.
Implants - under or over the muscle?
I rarely go over the muscle. In my opinion, under the muscle results in a more natural look and feel, lower incidence of capsular contracture and less interference with mammograms. The downside is that there is more discomfort postoperatively and there can be distortion of the breast with contraction of the pectoralis muscle. This distortion is rarely an issue unless the patient does a lot of upper body stuff in a teeny, tiny bikini top.
I do go over the muscle in most body builders (see distortion issue above) and if I am treating a breast asymmetry and am concerned the submuscular implant will ride too high compared to the other breast.
In cases of mile ptosis (sagging), I still go submuscular but do a lift to center the nipple.
Seattle Plastic Surgeon, Dr. Lisa Lynn Sowder
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.