Should I have my implants placed over the muscle so I can continue with frequent push ups and pull ups?

All of my 7000 breast augmentation patients have breast implants under the muscle. I have a couple of triple crown body builders and many very athletic patients. None have reported any loss of strength. If Training for a Competition, I advise my patients- Three weeks after surgery, it’s OK for you to do aerobic activity (treadmill, stationary bike, etc.), running and lower-body weight training. Women are usually comfortable doing arm exercises (upper-body weights) starting about six weeks after surgery. Among my patients are Triple Crown bodybuilders and kickboxers who go back into competition after getting implants. They start with light training at six weeks and heavier training after eight weeks. Always a good idea to check with your surgeon's protocol.Dr. Ted Eisenberg, Board Certified Plastic Surgeon and AuthorRealSelf Distinguished Hall of Fame Inductee

Excellent question.  Please read Dr. Singer's very complete answer below.   Excellent answer.The shorter answer is  - it is all a trade off that you should discuss with your plastic surgeon, and a lot depends on how much subcutaneous fat and breast tissue you have to cover the implant, how large you want to go, and the activity you plan on doing.I predict you will choose above the muscle and maybe an extra fill silicone implant to reduce the likelihood that you will have ripples that will be seen or felt.

As a bodybuilder, I augment professional athletes frequently.  I think for those people in whom the living is made by athletic performance, the implant can be placed above the muscle.  Other patients will be happier longterm with submuscular (dual plane) placement.

Thank you for your question. It is not uncommon for very active women, including competitive body builders, to want to avoid negatively impacting on the function or strength of their pectoral muscles. As you may well know, placing the implant under the muscle helps conceal the edge of the implant, particularly in the upper pole, thus helping the appearance be more natural, and making the implants less obvious. The other advantage of placement under the muscle includes a reduced risk of capsular contracture (unwanted tightening and firmness surrounding the implant) and better breast visualization with future mammograms. The advantage of placement above the muscle is that the muscle remains totally undisturbed, but you are risking implant visibility or palpability, including rippling. If, however, you have an adequate amount of breast and subcutaneous tissue, placement above the muscle may be a good option for you. Please consult with an experienced board certified plastic surgeon who can advise you specifically as to which option and treatment plan would be best for you after evaluating you in person. Best of luck to you. 

Dear MaryV123,
I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Thank you for sharing your question.  For most patients, even those very used to do HIIT and other intense exercises the benefits of going underneath the muscle outweigh those to go above.  I would continue to discuss your concerns with your surgeon so that you can have the question fully answered to your satisfaction.

Hello and thank you for your question. There are several advantages and disadvantages to over vs under the muscle.  Under the muscle has the advantage of lower capsular contracture rates, less risk of rippling, and better visualization with future mammograms.  Most patients say that under the muscle also has a more natural look and feel.  The size, shape, and profile of the implant is based on your desired breast size/shape, your chest wall measurements, and soft tissue quality.  This decision should be based on a detailed discussion with equal input from both you and your surgeon.  Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.   Best wishes and good luck.


Richard G. Reish, M.D.  FACS

Harvard-trained plastic surgeon
 

Dear Mary, thanks for reaching out on this platform. In women such as yourself I would definitely advise to go over the muscle (i.e. subfascial or subglandular plane) instead of behind the muscle.
Whether or not you are a good candidate for that approach is also subject to a proper examination by a board-certified plastic surgeon who has to assess whether you have the right tissue quality for that (sufficient "pinch" as plastic surgeons call it). Hope this is helpful. 
All the best.

Thank you for the excellent question. This is a contentious topic amongst Plastic Surgeons. In the distant past, placement was completely submuscular. While this was a good approach in terms of capsular contracture, but the procedure was fairly morbid. Surgeons later converted to a partially submuscular placement where the upper portion of the implant is under muscle and the lower portion is under gland. This has certain aesthetic benefits. However, the implant is still exposed to breast tissue in the inferior pole.  For my athletic clientele, I use a subfacial approach where the facia over the muscle is lifted up. This is a less common approach in the states. In my hands and in the hands of people who perform this procedure regularly including surgeons in Brazil, the contracture rates are similar to a partially submuscular placement. Interestingly, more recent data out of Canada suggested even subglandular placement of more modern implants have a contractual rate that is also fairly low. We still don’t completely understand the etiology of contracture and the role of implant placement. That being said, I would see as many surgeons as you can and if you do choose to go above the muscle, preferably in a subfascial plane, choose a surgeon who has used this technique for years. I’ve been doing it for about eight years now

There are two choices for breast implant placement: sub-glandular (under the breast tissue and in front of the chest muscle – the pectoralis muscle) or sub-muscular (under or partially under the chest muscle). The best location depends on many factors including: tissue thickness, weight, desired outcome, and individual anatomy. Each position has advantages and disadvantages:

Subglandular implant benefits:

A shorter recovery time.
Less discomfort initially.
No distortion of the breast when the pectoralis muscle flexes.
Mild preoperative sagging can be improved, especially if no breast lifting procedure is performed.
Easier surgical procedure.
Larger implants can be placed.

 Subglandular implant disadvantages:

The implant may be more visible.
More visible rippling, especially in patients with a small amount of natural breast tissue.
Generally, saline implants do not produce a good result in front of the muscle.
Higher incidence of capsular contraction.
“Bottoming out” in some patients.
Some radiologists have more problems reading a mammogram with an implant in front of the muscle.

 Submuscular implant benefits:

Usually results in a better appearance for naturally small breasted women
Less tendency for seeing ripples of the implant.
A more natural feel to the breast especially in slender women who don’t have much of their own breast tissue.
Less interference with mammograms, although most radiologists take additional views no matter where the implants are placed.
Lower rate of capsular contraction.
Less of a chance of “bottoming out” where the implant bulges at the lower aspect of the breast and the nipple and areolas tend to appear excessively elevated.

Submuscular implant disadvantages:

Recovery usually takes a little longer and is more uncomfortable initially.
There may be an “animation deformity”, which is a temporary distortion of the breasts when the pectoralis muscle is flexed. Body builders and weight lifters generally prefer implants in front of the muscle.
It is harder to achieve cleavage in women who have widely spaced breasts.
The implants often ride higher on the chest.

Actually, most patients who have breast augmentations today have breast implants placed in a combination or “dual plane” position. This approach has the same benefits and disadvantages of a total “submuscular implant”, but with a lesser tendency to ride high on the chest wall. The disadvantage as compared to a total “submuscular implant” is a higher tendency for bottoming out.

The ideal placement in any particular patient depends on their particular anatomy and understanding of the pros and cons of each approach and desired outcome..

Keep in mind, that following the advice from a surgeon on this or any other website who proposes to tell you what to do based on two dimensional photos without examining you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of each operative procedure may not be in your best interest. I would suggest you find a plastic surgeon certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person.  

Robert Singer, MD  FACS

La Jolla, California