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Should Breast Implants Be Placed Under or over the Muscle?

my friend went under the breast muscle w/ her implants...but now it looks rippling on the bottom. During consultation with a respected plastic surgeon in LA he told me under the pectoral muscle is much better... less risk from capsular contracture, safer for breast cancer screening, more natural (less stripper looking...his words, not mine!). Thoughts?

Doctor Answers 73

Breast Implants Under 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.


Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 66 reviews

Over or under muscle placement of breast implants

One of the primary choices in breast augmentation is whether to have the implants placed "under" or "over" the muscle (submuscular or subglandular). This muscle is the pectoralis major muscle which lies over the rib cage and underneath the breast. It is the chest muscle that is commonly developed in weight lifters.

Traditionally, when the majority of implants were silicone, implants were most often placed underneath the breast gland and on top of the muscle. With the more common use of saline filled implants, it was noticed in women who were thinner or who had relatively little breast tissue to cover the implants, that there was a tendency to develop "rippling" or a waviness in the skin overlying the implant. This is especially true with the use of the "textured" or rough surfaced implants. In an effort to decrease the incidence of rippling and the potential for capsular contracture, there has been a move to place implants in the space beneath the pectoralis major muscle. Submuscular placement increases the padding overlying the implant offering more coverage and camouflage to the shape of the implant. Using this technique, rippling has become a rare problem

Today many more women have the option of silicone implants. The silicone implants are softer, re realistic in fell and the tissues tend to drape over them more realistically. They are also less prone to rippling. Consequently, it is possible to place them in a subglandular position more often while decreasing the risk of rippling. In fact a possible solution for rippling saline implants can be to replace them with silicone implants.

There are, however, some breast shapes that are better suited to a subglandular ("over" the muscle) placement of the implant. These women typically have breasts that at one time were much larger than the present. When there is a very large volume decrease and there is little or no shrinkage in the size of the skin envelope surrounding the breast tissue, then the shape approaches that of an "empty bag". Under these circumstances it is sometimes better to place the implant in a subglandular position in order to allow the implant to fill out the skin envelope of the breast.

Alexander G. Nein, MD
Nashville Plastic Surgeon
4.5 out of 5 stars 17 reviews

Breast Implants Under or Over the Muscle-Which is Best

Opinions certainly vary but among most Plastic Surgeons today the most common answer you will get is under the muscle.

Benefits include:

  • ·         More tissue covering the Breast Implant
  • ·         Less risk of Visible folds or Ripples
  • ·         Less risk of firmness or capsular contracture

However Breast Implant under the Muscle can have disadvantages:

  • ·         More painful and longer recovery
  • ·         Visible muscle contraction around Implant during activity
  • ·         Interference with Pushups and weight lifting
  • ·         Higher position of Breast Implant which can cause unnatural look in sagging Breast
  • ·         Requires Breast Lift with extra scars if Breast is sagging

Breast Implants are still placed under the Breast in many people and can produce an equally nice natural looking result. Reasons for choosing under the Breast include:

  • ·         Easier Recovery
  • ·         A slightly sagging Breast when you do not want to have a lift
  • ·         Women with full Breast and adequate Breast Gland Tissue

It is wrong to be dogmatic and say there is only one way to place Breast Implants. You need to find an experienced Board Certified Plastic Surgeon and discuss your individual needs and preferences. See link below.

Under the Muscle is Usually Better for Breast Implants


Under the muscle is best for:

  • thin women
  • women with little breast tissue to cover the implant
  • women with little or no drooping of the breast
  • softer, more natural draping of the implant
  • concealing implant ripples
  • less chance of developing capsule contracture


Over the muscle is best for:

  • faster recovery
  • women with enough natural breast tissue to cover the implant
  • women with drooping who want larger breasts without a breast lift

 

These generalizations are meant as a guide: the best way to determine the optimal option for your particular anatomy and goals is in consultation with your plastic surgeon.

Paul C. Zwiebel, MD
Denver Plastic Surgeon
4.0 out of 5 stars 17 reviews

Why put breast implants either under or over the muscle?

I always say the same thing to my patients:  easier to get good mammograms, lower risk of capsular contracture, better camouflage of the upper edge of the implant by the muscle. So yes, all of the above, but don't forget that the implants are not covered by the muscle in the lower half of the breast. That's why you can still feel the rippling at the lower part of the breast if you have thin skin.  

And that is why a lot of women are choosing gel implants. Because even if you can still feel the implants, they feel softer and smoother when they are gel.  If you get saline implants I think it is important that they not be under-filled because they will feel more wrinkly.  I usually fill them up 10% over the minimum rated volume, e.g., a 300 gets filled to 330.  This helps.

Robert M. Lowen, MD
Mountain View Plastic Surgeon
5.0 out of 5 stars 34 reviews

Above or below pectoralis muscle for breast implants - Submuscular implants

Breast augmentation should generally be made under the pectoralis muscle to decrease descent of the implant, capsular contracture, and palpability of the implant.  There are only a few cases that necessitate subglandular breast implant placement. 

Raffy Karamanoukian, MD, FACS
Los Angeles Plastic Surgeon
5.0 out of 5 stars 64 reviews

Breast Implants, under vs over the muscle

Under the muscle placement is actually a misnomer, since the upper portion of the implant is placed under the pectoralis muscle, but the lower portion resides beneath a woman’s lower breast tissue.  It therefore should be more accurately labeled “partial submuscular placement”.  Implant location is based on how much soft tissue- muscle, fat and existing breast tissue- a woman has.  In general, small breasted women and most with moderate sized breasts would benefit from camouflaging their implants from showing rippling through the skin by placing them under the muscle to afford more padding over the implant surface.  Those women who have naturally large breasts and want to be larger with implants (rarely seen by me) could have the implants placed over or under the muscle to get a similar result. 

Steven Yarinsky, MD
Albany Plastic Surgeon
4.5 out of 5 stars 7 reviews

There are several considerations that determine what may look best for you, and in some women either placement is a good option.

This is a good question and a very common one that patients ask. There are several considerations that determine what may look best for you, and in some women either placement is a good option. Confusion about implant plane is one of the reasons our office staff decided to write a new eBook about breast augmentation called "A Girlfriend's Guide to Breast Augmentation". It is a free download and I am attaching a link for you.

Here are the pros and cons of both placements.

Submuscular/ Under the Muscle
Here’s my recommendation: Choose the submusular (under the muscle) placement if you have saline implants, a small amount of natural breast tissue or a strong family history of breast cancer.

Placing the implants under the muscle has the advantage of having more of your breast tissue over the implants, and may make the implants look more natural and less obvious. For this reason, I recommend that most saline implants be placed beneath the muscle. Saline implants are slightly firmer or stiffer, and may require the pressure of the muscle to give a better shape to the upper part of the breast. Implants may remain a little softer under the muscle and may be less easily felt, particularly with saline implants. Rippling, which is more common with saline implants, will be less obvious under the muscle.

However, all implants beneath the muscle are subject to “animation distortion.” As the muscle contracts over the implant, it can temporarily change or deform the shape of the breast. While this is not a permanent situation (it goes away once the muscle is not flexed), it can be a concern to some patients, particularly body-builders. There will be a decrease in chest muscle strength after the surgery, but this will recover.

Submuscular placement is more uncomfortable initially, and may always have a slightly different sensation to the patient. There may also be a slightly greater risk of “bottoming out” with submuscular placement than with subglandular placement.

Some believe that mammography may be more easily done if the implant is submuscular because there will be an additional layer of tissue between the implants and the breast tissue.


Here are advantages to placing the implants under the muscle:
• The implant is less visible and looks more natural.
• It’s harder to feel the implant and therefore it feels more natural.
• There is less rippling if you decide on saline implants.
• Possibly there is better breast imaging with mammography.


The disadvantages to placing the implants underneath
the muscle are:

• It is more uncomfortable and involves a longer recovery.
• There is animation distortion when the chest muscles are flexed.
• There is a possible increased risk of “bottoming out”.

Subglandular (Over the Muscle)
Here’s my recommendation: Choose the subglandular (over the muscle) placement if you want silicone implants, have a large amount of natural tissue with saline implants or require a breast lift.

The subglandular placement is more common with silicone implants because they are softer and do not require as much tissue coverage for a good shape. The subglandular placement is also for women with greater amounts of natural breast tissue. If you already have a moderate amount of breast tissue, you may achieve a more natural shape with the implant in the subglandular position, particularly with silicone implants, because there is no muscle interposed between the implant and the breast tissue. Women with greater amounts of breast tissue, using a smaller (relatively speaking), saline implant, can also use the subglandular position.

There is no animation distortion of implants in the subglandular plane. The operation is less painful, the recovery a little shorter, and there may be a more natural sensation for the patient. However, rippling can be more visible which is why saline implants should not be placed over the muscle in women with very little breast tissue.

In breast lifts, it is more common – with the technique I use – to place the implants in the subglandular position. This allows a better ability to mold the shape of the breast and the implant as a single unit.

Here are the advantages of placing implants over the muscle:

* There could be a more natural-looking shape of the breast (particularly with silicone).
* The recovery is less painful with a shorter recovery time.
* There is no animation distortion when the chest muscles are flexed.

 

The disadvantages of placing the implants over the muscle are:

* The implants are more visible and palpable, especially with saline.
* There is a greater chance of rippling

David B. Reath, MD
Knoxville Plastic Surgeon
5.0 out of 5 stars 96 reviews

This is why I prefer to place breast implants below the muscle...

For most of my patients, placing breast implants below the pectoralis muscle is preferable. Implants placed below the muscle will have the following benefits:

1) Reduced risk of capsular contracture

2) Reduced risk of infection

3) Reduced risk of implant exposure

4) More natural appearance; especially on the upper portion of the breast.

It is important to realized that implants placed below the muscle, are mostly below the muscle...not completely below the muscle. In almost all women, there is no definable pectoralis muscle underlying the lower outer portion of the breast. Therefore, the ability to feel and see the implant below your breast skin in this location always exists.

Kevin Brenner, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 17 reviews

Breast Implant Placement - Over vs Under the Muscle

Best practices are to place the implant under the muscle, although there are rare cases where it is better to place the implant over the muscle. The reason why it is better to place the implant fully under the muscle or partially under the muscle is because it creates a more natural look and feel, reduces the risk of capsular contracture and allows for significantly more visibility during a mammogram.

With saline implants, rippling can occur whether the implant is placed over or under the muscle. This is due to the structure of the round implant and the amount of tissue covering the implant. This occurs more commonly in patients who have undergone breast augmentation over the muscle, but is also seen in thin patients. Silicone implants are often a better choice if you are concerned with rippling. They also have a more natural feel because they more closely resemble the texture of natural breast tissue.

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.