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Under the Muscle Vs. Over the Muscle? What's Really the Best Decision?

I have been to two consults. One doc says under, another says behind. Should I get a third opinion?

Doctor Answers (18)

Breast Implants, Under or Over the Muscle...

+4

When you have made the decision to have Breast Augmentation it can be difficult to know who to trust to obtain the best results.  Typically the implants are placed under the muscle to reduce the chance of rippling due to lack of breast tissue.  Some surgeons may recommend placing the implant above the muscle if the patient works out a lot or does heavy lifting daily.  In addition, it may be placed above the muscle if the skin has some laxacity in it.  I would speak with both plastic surgeons to see why they prefer their approach and then make your decision.


Edison Facial Plastic Surgeon
4.5 out of 5 stars 39 reviews

Time for the opposite opinion

+3

I have been doing this surgery for over 35 years. In the beginning all implants were placed above the muscle, then an article came out claiming that under was better - so we switched to that. Turns out it isn't. When we went to saline implants, they needed the added cover of muscles to hide the rippling, now that we are back to silicone, I put most of them under the breast ( over the muscle). Ask yourself, "Where is your breast tissue?" The answer is Over the Muscle not under it. Also, even when the implants are placed under the muscle, only the top 1/3 to 2/3s is covered by muscle, the rest is just under the breast tissue.

Implants placed under the muscle have a tendency to ride up and appear higher because often the medial portion of the muscle is not adequately released. Also, putting them under is more painful and can deform the implant when the muscle contracts.

 

So you can see, I like to put them over the muscle.

William B. Rosenblatt, MD
New York Plastic Surgeon
4.0 out of 5 stars 9 reviews

Breast implants and your pectoralis muscle.

+2

The decision to place implants under or over the muscle depends on both anatomy and goals from surgery. In general, thinner women with little breast tissue will benefit from the improved soft tissue coverage of an implant under the muscle. However, other women will choose to have a more visible implant to avoid the distortion that can occur from submuscular implants when the pectoralis muscle flexes. A thorough discussion of your goals combined with a detailed examination is the key. You have seen two surgeons and had two opinions. Their reasons for implant placement should be clear and consistent with your goals from surgery. If they aren't, then you should seek a surgeon whose recommendation makes sense to you.

David Bogue, MD
Boca Raton Plastic Surgeon
5.0 out of 5 stars 12 reviews

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Breast Implant and placement above or below the muscle

+2

There are a variety of opinions as to whether a breast implant is best  placed above or below the pectoralis major muscle.  After 25 years of practice and having placed several thousand breast implants, I do not believe there is necessarily a right or wrong answer to this question.  Each implant placement position has its potential advantages (BELOW THE MUSCLE - lower contraction rate problems, easier to read mammograms, may hide the implant better, etc. while ABOVE THE MUSCLE - less risk of displacement during exercise, may fill out the breast better in a case of breast involution or tuberous shaped breast,  may allow for the placement of a larger implant, etc.) .    A surgeon needs to evaluate each patient individually, not only from an anatomical perspective, but also from the standpoint of the patient's desires and expectations, to determine which implant position is best in their particular case.  I would check to see that the surgeon you choose to do your surgery is comfortable with placing breast implants either above or below the muscle and ask why they would suggest one position over the other in your case.  Best of luck. 

Vincent D. Lepore, MD
San Jose Plastic Surgeon
5.0 out of 5 stars 17 reviews

Under the Muscle Vs. Over the Muscle? Best Decision?Answer:

+2

The thought keeps changing and will probably continue to do so! My colleagues in Brazil all go over the muscle but use the newer gel implants which are shaped and textured. So what it really seems to come down to is what result you are looking for and how much breast tissue you have to begin with. In lean women, under hides the implant better. And although I agree that in nature your breast sits on top of your muscle, the under muscle space seems a great location to have an implant placed.

John J. Corey, MD
Phoenix Plastic Surgeon
5.0 out of 5 stars 18 reviews

Breast Implant Placement Over the muscle vs. behind the mucle

+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 41 reviews

Over Or Under Muscle?

+2

Although I placed all breast implants over the muscle 25 years ago when I first started my practice, it is extremely rare for me to do so at this time.  Implants placed under the muscle tend to be softer and more naturally appearing and feeling, especially if they are silicone.  The main downside is more discomfort during the first few days post-op.

John Whitt, MD
Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Best to place implants over or under the muscle?

+2

Placement depends on the implants you select (size and composition), how lean your body is, how much breast glandular tissue you're starting with, how active you are with your upper body, and your personal preferences.   Because every woman is different, for many, subglandular is best.  For others, submuscular is best.  Either choice produces acceptable results when the procedure is well executed.

Steve Laverson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 38 reviews

Under v. over the muscle

+2
Most of my patients have implants inserted under the muscle. This avoids rippling in patients wtih thin skin, better pads the implant, makes mammography simpler and has a lower incidence of capsular contracture. The patient who opts for implants over the muscle is generally someone who wants implants badly but is unwilling to undergo the longer recuperation or is extremely fearful of postoperative pain. Ultimately, the patient, not the doctor, must own the decision and the consequences. I understand that this is a difficult thing for patients to do and that augmentation involves a series of choices which complicates things--under v. over, smooth v. textured, saline v. silicone, high profile v. moderate profile, one size v. another. This is a reason why the decision making should not be spontaneous and requires a great deal of dialogue between patient and surgeon.

Robert L. Kraft, MD
New York Plastic Surgeon
5.0 out of 5 stars 11 reviews

Most patients will have implants under the muscle

+2

The vast majority of patients will have their breast implants placed under the pectoral muscle (subpectoral). There are many advantages for this: easier to read mammograms, more natural appearance, easier to breast feed and lower risk of capsular contracture(scar tissue). There are not many good reasons to place a breast implant in the subglandular (above the muscle) location other than the faster recovery. A board certified plastic surgeon can evaluate your specific anatomy and determine which is the best approach for you.

Best wishes,

Dr.Bruno

William Bruno, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 148 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.