Can Breast Reconstruction Be Done with the Implant on Top of the Pectoral Muscle?

I am facing a right mastectomy with reconstruction. I am small busted, A cup or smaller. I am not interested in being larger at all. Can I choose to have the implant placed on top of my pectoral muscle, similar to regular augmentation? I have read about "bottoming out" but I do not want a big or heavy implant. Will my skin be able to hold this up. I am hoping I qualify for a skin sparing mastectomy. I have DCIS and will not need chemo or radiation.

Doctor Answers (12)

Implant reconstruction

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Implant based reconstruction can be done single stage or double stage.  Most commonly, implant reconstruction is performed in two stages where tissue expander is placed under the pec muscle with Alloderm/Strattice as a sling for the first stage and tissue expander is exchanged to final implant for the second stage.  Tissue expander/implant should be placed under the muscle because after the mastectomy, the remaining breast skin is very thin (unlike breast augmentation that has breast skin as well as breast tissue).  Here are some of the reasons why implants should be placed under the muscle: 1) If the implant is placed just under the breast skin, you are going to feel "rippling" (folds of the implants) more, 2) In case of wound healing problem, the likelihood of implant extrusion will be higher, 3) You will have a better cosmetic result with muscle coverage with Alloderm/Strattice sling technique.  


Houston Plastic Surgeon
4.5 out of 5 stars 40 reviews

Implant Based Breast Reconstruction

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I am sorry to hear of your diagnosis and hope the answers here help you make the most educated decision. 

First off, I do not believe it is safe to place an implant above the muscle.    Patients with little to no breast tissue are at unacceptably high rate of capsular contracture (scar formation) and infection by over the muscle implant placement.  

The pectoralis muscle has a wonderful blood supply that can not only reduce complications, but reduce visibility of the implant.    In addition, the pectoralis muscle provides a barrier of protection should you have any wound healing problems from your mastectomy.

I wish you a safe and healthy recovery.

Paul S.Gill, M.D.

Gill Plastic Surgery

Houston Double Board Certified Plastic Surgeon

Paul S. Gill, MD
Houston Plastic Surgeon
5.0 out of 5 stars 42 reviews

Generally NOT Advisable to Have Reconstrcuction with an Implant Above the Muscle

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Breast implants used in reconstruction cannot generally be placed directly in the space created by the removal of breast tissue. This is because an implant placed directly below the skin will generally not produce cosmetically desirable results and will be at high risk for eroding through the surgical incision, or through the skin itself. Consequently, breast implants used for breast reconstruction are almost always placed below the pectoralis muscle.

Preparation of the mastectomy site for reconstruction with an implant therefore usually requires the additional insertion of one or both of these:

  • A tissue expander (a device that is temporary implanted to stretch the skin for a period of time—usually several months—prior to placement of the implant)
  • A tissue matrix such as AlloDerm® (a tissue substitute derived from cadaver skin or another similar product)

Tissue expansion followed by implant placement is the most common method of implant-based breast reconstruction. This approach to breast reconstruction requires two separate surgical procedures.

In order to create space and prepare the chest for reconstruction using a breast implant, a tissue expander can be used to progressively stretch the muscles of the chest, and often the skin as well. An expander is like an adjustable balloon that is gradually inflated over a period of several months to make enough room to accommodate an implant behind the stretched-out muscle. Women who undergo expander/implant reconstructions typically visit the plastic surgeon every few weeks after surgery to have the expander filled by injection with sterile fluid.

Because an expander cannot be fully inflated when it is first placed, a woman undergoing this method of reconstruction will not have a new breast right after her mastectomy surgery. Once ample expansion is achieved, another surgery will be required to remove the tissue expander and replace it with a breast implant.

I hope this is helpful.

David Greenspun, MD, MSc
New York Plastic Surgeon

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Implant reconstruction after mastectomy

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I'm sorry you are dealing with breast cancer, but it sounds like you are doing your research and really taking ownership of your reconstruction options.  Good for you!

You can certainly have a small implant for your reconstruction, which will minimize many of the potential complications (bottoming out, wrinkling, rippling, extrusion, etc).  However, I would not do a reconstruction with an implant above the muscle.  The implant needs as much coverage as possible, or you will certainly deal with implant wrinkling, rippling, palpability, increased risk of capsular contracture, and extrusion.  Placing the implant below the muscle will not increase your risk of bottoming out. 

Be sure that you meet with a plastic surgeon before your mastectomy.  You'll want your plastic surgeon and your general surgeon to work together during your mastectomy and reconstruction.  Best wishes!

Carmen Kavali, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 23 reviews

Breast reconstruction

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Breast implants need good coverage to minimize complicatins. Skin sparing mstectomy leaves thin skin. therefore the implant need to be under the muscle in the upper part and Alloderm in the lower part, or a flap.

Your plastic surgeon should be in the operating room at the time of themastectomy and see the thinness of the skin and be in contact with your oncologist before surgery to discuss the need for radiation. If radiation is contemplated then another form of reconstruction should be discussed with you

have a second and third consult with a BOARD CERTIFIED PLASTIC SURGEON, BEFORE THE ACTUAL SURGERY TO DISCUSS ALL YOUR OPTIONS IN RECONSTRUCTION

Samir Shureih, MD
Baltimore Plastic Surgeon

Breast Reconstruction Using Implants

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Implant reconstruction can be performed on top of the muscle BUT is not recommended or routinely performed.  The reasoning in my mind is that if implant is place above the muscle then there is very little protection for the implant and the wrinkles in the implant surface can be easily seen.  More importantly, there is decreased chance for capsular contracture if the implant is placed beneath the muscle.

Dr. ES

Earl Stephenson, Jr., MD, DDS
Atlanta Plastic Surgeon
5.0 out of 5 stars 9 reviews

Breast Reconstruction Be Done with the Implant on Top of the Pectoral Muscle

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Your request is possible but not advisable because of the thinness of the skin and sub cutaneous tissue needed to cover the implant/expander. I have done this requested placement with success but I ALWAYS advise to have good muscular coverage. PLEASE discuss with the reconstructive plastic surgeon. Best of luck. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.5 out of 5 stars 64 reviews

Breast reconstruction

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If you are having breast reconstruction after a mastectomy, you will not have any breast tissue to cover the implant.  This will not look natural and there will be an increased risk of implant extrusion due to lack of soft tissue coverage.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 18 reviews

Breast Reconstruction with an Implant over the muscle / Under the Skin is a BAD Idea

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Regarding:"Can Breast Reconstruction Be Done with the Implant on Top of the Pectoral Muscle?
I am facing a right mastectomy with reconstruction. I am small busted, A cup or smaller. I am not interested in being larger at all. Can I choose to have the implant placed on top of my pectoral muscle, similar to regular augmentation? I have read about "bottoming out" but I do not want a big or heavy implant. Will my skin be able to hold this up. I am hoping I qualify for a skin sparing mastectomy. I have DCIS and will not need chemo or radiation
."

Take a ziplock bag. Fill it with water and carefully watch the rippling on its top. Breast implant, both silicone gel and salt water filled acts similarly. Both types of implants ripple when held sideways. For this reason, "natural", or better described, attractive breast augmentation results are only obtained when the existing breast tissue can cover the flaws of the implant which merely acts as a booster seat for the overlying breast. Whenever the implants are not well covered (women with little available breast tissue to cover implants (IE A cups) or not fully covered (IE implants larger than available breast tissue), the rippling of the implants cannot be masked. The same A cup women who insisted on having D cup breasts then complain WHY are they filling and seeing ripples.

In a Mastectomy, the breast gland, by definition, is removed leaving only a thin skin lying on top of muscle. Placing ANY implant under a skin flap would look MUCH WORSE than the A cup to D cup  augmentation since having NO breast tissue cover is worse than having little breast tissue cover.

As a result the answer is to place the implants under the pectoralis muscle and if needed consider using an acellular dermal matrix sling to both cover the lower pole of the breast and prevent sagging.

Good Luck with your surgery.

Dr. Peter Aldea

Peter A. Aldea, MD
Memphis Plastic Surgeon
5.0 out of 5 stars 66 reviews

Subglandular breast Reconstruction not recommended

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I can not in good conscience even recommend a subgland reconstruction after a skin sparing msctectomy.  It is an entirely different animal than a breast aug.  The tissue is removed and there is virtually no tissue remaining other than a very small amount of fat on the skin.  If you are very thin I would absolutely recommend going sub pectoral and using a dermal substitute like Strattice or Alloderm to supplement the result.  I hope this helps you and I suggest getting several opinions.  If no one is willing to do a subgladular there has to be a reason why.

 Best of luck from Dr. Schuster in Boca Raton

Steven Schuster, MD
Boca Raton Plastic Surgeon
4.5 out of 5 stars 3 reviews

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.