What is the Difference Between over the Muscle and Under the Muscle Breast Implants?

Implant placement relative to the pectoralis major muscle
continues to be a source of controversy.Although the majority of plastic surgeons prefer submuscular placement,
there is still a large group of plastic surgeons who feel strongly about
subglandular placement.Each group can
make convincing arguments regarding their position of choice.It’s safe to say both approaches have
advantages and disadvantages.In the
context of these discussions, we feel that every patient needs to be considered
individually.Each patient has unique
anatomic findings that affect the decision to place the implant under or over
the muscle.The aesthetic goals of the
patient are equally important and have a significant impact on the decision as
well.The vast majority of patients are
striving for larger breasts with a natural look.They want balance, harmony and proportion
with the surrounding structures.The
majority of breast implants are placed in a submuscular position.There are several advantages to this
approach.These include more soft tissue
coverage which results in fewer visible folds, creases and ripples in the
implant.This is especially important in
women who have thin skin and minimal breast tissue who want saline implants. Another
advantage of submuscular placement is a lower incidence of capsular
contracture.This phenomena results in
hardening and distortion of the breast.Patients can also have significant pain with capsular formation.Capsular contractures can occur with the
implant in either position but the incidence is higher when the implant is
placed on top of the muscle.For these
reasons, submuscular placement gives a more natural look in most areas. Placement
of the implants on top of the muscle should be considered in female body
builders who have large muscles which can distort the implants during
contraction.In women with breast sag,
implants can be placed on top of the muscle to avoid a breast lift and
scarring.Every
patient should be considered individually.It’s important that you meet with a board certified plastic surgeon who
can help you obtain your aesthetic goals.

It's a great question. I strongly prefer under the muscle implants because the muscle provides another layer of camouflage for your implants. The muscle contours the top of the implant to give it a more natural slope and implants under the muscle have a decreased risk of scar tissue forming around the implant (capsular contracture). Although an implant on top of the muscle can be a good choice for some women, for very thin women there is not enough camouflage for the implant to look natural. When considering breast augmentation make sure you find a board certified plastic surgeon who will take the time to answer all of your questions and explain all of your options, so that you can decide if breast augmentation is right for you.

Thank you for your question. Below I've provided descriptions of each of the breast implant placements. If you'd like more detailed information and a diagram to explain the different implant placement options, you can take a look at my Guide to Breast Augmentation on my website in the web reference below.Submuscular implant placement: Dr. Zuckerman would make the pocket completely underneath the pectoralis major muscle. It is the most common placement he does, and it is also the most common placement for breast augmentation nationally. It is a simple placement, with a relatively bloodless dissection plane upon implant placement. This placement puts good tissue over the implant, and there is some thought among plastic surgeons that is creates less propensity for capsular contracture.
Subglandular implant placement: Dr. Zuckerman would make the pocket underneath the breast gland but on top of the pectoralis major muscle. This placement has fallen out of favor somewhat, but it is a matter of preference for the surgeon. If the patient has a very muscular chest wall such that when flexing, the implant may move significantly, Dr. Zuckerman might recommend avoiding the submuscular placement and to use sublandular. To some extent, this is also true for those with very little starting breast issue. This is the original implant placement location and was favored in the 1980's.
Dual-plane implant placement: Dr. Zuckerman would make the pocket under the pectoralis major muscle, similar to a submuscular placement, and then free up the interface between breast gland and the muscle so that the breast implant slides. In this placement, the breast implant contacts the bottom part of the breast gland, which hinges the breast mound & tissue to give a little bit more of a lift out of your augmentation. There are three variations of this technique depending on how much of the interface vertically is freed up, and which variation to choose depends on how much lift you would like to achieve. However, this placement cannot be used in place of a mastopexy.

Hello! Thank you for your question! Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts. Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years. In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance. Your breast width is the most important measurement. Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant. This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape. Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width. Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later. Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle). Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each. In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome. A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles. Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions. As you see, there are a few factors to decide upon for incision, placement, and implant type/size. Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits. Hope that this helps! Best wishes for a wonderful result!

Submuscular placement may be more uncomfortable the first few days following surgery. The possible benefits of submuscular placement are that it may result in less palpable implants, less capsular contracture, and it will make it easier to image the breast with mammography. The appearance may be more “natural” for patients who are very thin. Subglandular placement may make your surgery andrecovery shorter and you may have less discomfort. This placement may provide a slight “lift”. Subglandular placement may result in more palpable implants, more capsular contracture and more difficult imaging of the breast with mammography. This placement is often recommended for those patients with sagging, but do not want a breast lift (mastopexy) and for tubular breast deformity

SUB-MAMMARY POCKET (over the muscle)The implant is placed over the chest muscle, under only the breast tissue.- good for women with more of their own natural breast tissue so the implant can be hidden better. Also good for tuberous breasts.SUB-PECTORAL POCKET - Dual Plane (under the muscle) - more commonThe top part of the implant is placed under the chest muscle and the bottom third is covered by breast tissue.  -creates a natural teardrop shape. The implant is better covered so it's better for women with less of their own breast tissue. Makes mammograms easier to read.

There are two optimum implant placement options: subglandular (between the pectoral muscle and breast tissue) and submuscular (under the pectoral muscle). Implant technology is not unique to placement. As an example, the new Gummy Bear implants may be placed over or under the muscle. Implant placement is one of the most important decisions you and your board-certified plastic surgeon will make as your care treatment takes shape. Of these two placement options, submuscular is generally the preferred approach. Medical data supports this - as does my experience (15 years + with a specialty in breast surgery). Submuscular placement reduces the risk of capsular contraction, rippling, malrotation and infection. Additionally, most radiologists will add that submuscular placement improves mammography; it is less likely that the implant will obstruct clear imaging of the breast tissue. Your research on implant placement may note that greater recovery time is needed for submuscular placement. Please know that if your surgeon is skilled, additional recovery time will not be required. In my practice, for example, patients resume normal activity in less than a week’s time and rigorous exercise in as little as two weeks. Generally, simple Ibuprofen is used for pain management.As your research continues, you may hear about the so-called sub-fascial implant placement. I would caution that this is more "marketing buzz" than it is good medicine. Fascial tissue is thin and very fibrous connective tissue that surrounds muscle throughout the body, including the pectoral muscle in the chest. Fascial tissue helps bundle muscle groups, blood vessels and nerves. Anyone who has ever skinned a chicken has seen fascial tissue. It’s that thin and amazingly stubborn layer of grizzly membrane over the muscle and meat. Similarly, in human anatomy, muscle and fascia are bound together. Attempts to separate the fascia and tissue to introduce an implant would be traumatic and ultimately ineffective. No place for an implant!Good luck to you as your research continues and thank you again for the question.

Thank you for your question. Breast implants under the muscle make it somewhat easier to get mammograms and have a slightly lower incidence of developing a hard scar. The muscle can also pad the implant in thin women to avoid severe rippling.  Women who have enough of their own breast tissue may be a candidate for over the muscle because their own tissue will pad and cover the implant making it less noticable. Both techniques are acceptable but selecting the right technique for the right patient is key. Implants under the muscle do bounce and jump with exercise.  I hope this helps.

I usually tell my patients that under the muscle gives you a more "natural" look and over the muscle gives more of a "wow" look. Under seems to have less hardening issues but it does have the "Animation effect" where the bottom of your breast tightens with pec flexion. Here in the states we do mostly below and in Brazil mostly above. There are some cases that really do need above the muscle but they are not as common.

Breast implants can be placed either under the chest muscles (sub-muscular) or over them (sub-glandular). Broadly speaking, patients with very small breasts are advised to have their implants placed under the muscle, as this provides additional coverage to the implant. This helps prevent visibility of the implant and camouflages rippling and wrinkling of the implant. Most patients who have sub-muscular implants notice that their implants sit high on the breast for the first few weeks after surgery. As the muscles relax, the implants settle and begin to lie in a more natural-looking position, so called “drop and fluff”. A potential downside of sub-muscular implants is “animation deformity”, which is movement of the breast implants seen with contraction of the chest muscles. This is an important consideration in someone who is a keen gym-goer or sportsperson.