What's Better - over Muscle or Under Muscle Implants?

Should I get my implants over or under muscle? I am recieving conflicting opinions from plastic surgeons.

Doctor Answers (22)

For flat breasts, breast implants work best under the muscle.

+3

Hi.

1) We individualize based on the anatomy.  For relatively flat breasts with no excess skin (like yours), I think under the muscle is better (more of your own tissue covering the implants).

2)  When you are trying to correct some sagging with implants, then over the muscle generally better (implants fill skin envelope better if they are over the muscle).

3)  For body builders, always over the muscle.


Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Breast Implants - Above or Below the Muscle?

+2
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.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 42 reviews

Breast implant placement

+2

There are various factors regarding how you want your breasts to look and feel, but if you and your doctor have a good, open line of communication, you shouldn’t need to go back and forth on your decision. A major factor that effects how breast implants look and feel is whether they're inserted over or under the chest (pectoral) muscle. I do submammary and submuscular implants, inserting the implants under the breast tissue and over the muscle through an incision in the breast fold. The result is fabulous: perkiness with barely a trace of scar.

If you want the most natural-looking breast you'll need a subpectoral implant, in which the implant is placed under the muscle. This procedure also requires the merest incision - about three centimeters in the crease under the breast or at the edge of the nipple -- and diminishes the incidence of capsular contracture, the formation of hard scar tissue around the implant which occurs in 10 to 30 percent of cases.

In short, you must know -- realistically -- what you are starting with, as well as what you want to look like when surgery is done. Do you want a natural appearance or a round, perky look? These are some of the factors I weigh with my patients when evaluating what type of procedure to do.

Michelle Copeland, MD, DMD
New York Plastic Surgeon
4.5 out of 5 stars 8 reviews

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Under or over

+1
There is no single approach that is ideal for every patient. Your surgeon will help you decide which implant pocket placement is best for you prior to surgery, taking special care to select one that will achieve your personal goals and expectations.

SUB-MAMMARY POCKET
In sub-mammary implant placement (also known as sub-glandular), the breast implant is placed between the breast tissue and the chest muscle.
This position is frequently recommended for women who already have a fair amount of breast tissue. They may also have a mild degree of breast droopiness (ptosis). A moderate amount of breast tissue will help conceal an implant placed in a sub-mammary pocket. In addition, a mild amount of breast droopiness can be corrected.
Sub-mammary pocket placement is also recommended for women with unusually shaped breasts, as the implants will help to change the shape of the breast better than implants placed in a sub-pectoral pocket.
Finally, professional, competitive body builders and fitness models are usually better off with implants placed above the chest muscle as well.
SUB-PECTORAL POCKET
In the sub-pectoral approach (also known as sub-muscular), the implant is placed under both the breast and chest muscle. The chest muscle covers the upper two thirds of the implant, while the bottom third is covered by your natural breast tissue. This allows for a tear-drop shape to the breast that looks more natural.
Generally speaking, sub-pectoral placement is more common than sub-mammary. The subpectoral breast implants are recommended for women who have minimal amounts of existing breast tissue. Because the chest muscle covers the majority of the implant, it will act like extra padding, making the implant less visible through the skin and 'feel-able'. Other advantages of sub-pectoral placement include a lower risk of capsular contracture (a condition that is characterized by an undesirable hardening of the breasts), and making mammograms easier to read (which can be beneficial for a woman with a family history of breast cancer).

Jerome Edelstein, MD
Toronto Plastic Surgeon
5.0 out of 5 stars 69 reviews

Over Muscle or Under Muscle Implants

+1
Each surgeon has his or her own preferences for the position of the implants based on experience and expertise. My general preference is under the muscle; however, the recommendation must be consistent with the patient's build and her needs/objectives. Choose the surgeon best understands your lifestyle, lifestage, needs and objectives, and has the demonstrated ability (through before and after photos) to provide you the look that you want.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon
4.5 out of 5 stars 18 reviews

Different opinions on this one

+1

personally, i place almost all of my implants under the muscle.  this is usually done in a "dual plane" fashion, meaning, the upper 1/2 of the implant is covered by the pectoralis muscle, while the bottom of the implant is covered by the gland. 

the main motivation for this is to help to camouflage the upper pole of the implant.  a simple look at your picture shows that your ribs are quite visible.  you do not have much soft tissue in this area, and using the pec to help cover the implants will help to soften the edges of the implant, and therefore camouflage the implants.

some surgeons who are older than i am, practiced in the era of subglandular implant placement.  my feeling is that the trend has definitely moved to submuscular placement of the implants.  that is where i would place your implants if i were doing the surgery.

Eric Chang, MD
Baltimore Plastic Surgeon
5.0 out of 5 stars 8 reviews

Location of Breast Implants

+1

Thank you for the question.

In my opinion,  there are numerous advantages of sub muscular (dual plane) breast augmentation. This  implant positioning will give you the best long-term aesthetic results and reduce the chances of complications such as significant rippling/comparability/ encapsulation and interference with mammography.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 779 reviews

Choose the "plane" which is optimal for your situation.

+1

Based on the photo submitted, I concur that the optimal position would be "dual plane": under the pectoralis major muscle in the superior portion and below the breast tissue in the lower pole.  This plane confers the following advantages: a) better superior pole (area between collar bones and nipples) soft tissue coverage, as the pec muscle drapes over the upper part of the implant; b) lower rate of capsular contracture (scar formation around the implant); c) superior imaging by mammography.  Dr. Placik has astutely pointed out that the differences between your breasts will provide more challenge for your implanting surgeon than deciding on the best plane. 

Some women are better served by subglandular (over the muscle positioning) a) those who have adequate upper pole coverage, typically >2cm by pinch; b) those with a "tubular" breast, which is a constricted base with sparse breast tissue under an overly enlarged nipple-areolar complex; c) body builders whose customary chest flexing poses typically cause lateralization of the breast implants.  Hope this helps.   

Lavinia Chong, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 40 reviews

The Unders Have It

+1

Dear Confused,

Although the choice of over versus under the muscle is there for almost everyone, certain body types lend themselves better to under the muscle.  Thin tissues on the chest wall such as yours is one of those body types.  Placement under the muscle would give you a thicker implant coverage a most likely a more natural result.  Also, placement under the muscle is less likely to result in tight capsular contractures, which can distort and displace implants.  Good luck!

Kenneth R. Francis, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 32 reviews

Which is Better OVER or UNDER the Muscle Breast Implant Placement

+1

All breast implants form ripples and folds (saline much worse than silicone filled). The most attractive breast augmentation results are obtained when the implant is covered completely by your tissues. Unfortunately, women present for breast augmentation precisely because they do not have sufficient breast tissues and want more volume. To cover the ripples of the implants, they are best placed under the pectoralis muscle under the breast in the majority of women.

Dr. Aldea

Peter A. Aldea, MD
Memphis Plastic Surgeon
5.0 out of 5 stars 63 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.