Should I be nervous about over the muscle silicone gel, more than I would be about under the muscle?

I'm 31, have breastfed two children. My pre-baby bra size was 34B. Now, I'm deflated and my bras are about half filled. I had my consult and he suggested silicone gel, over the muscle to give my breast the fullness I desire (I do like rounded appearance and higher placement) and to give a slight lift. Capsular contraction & mammogram issues are what makes me nervous.. Also, many posts refer to "thin girls" going under the muscle. I'm not bone skinny, but I'm of thin stature- 5'7, 135, size 4.

Doctor Answers 11

Above the Muscle Breast Implants

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Your worries about sub glandular (above the muscle) are not warranted. When sub glandular implants are textured, there is no difference in capsular contracture when the sub muscular implants are smooth. When mammograms are diagnostic, not screening, mammograms are as reliable as those done in unaugmented breasts, whether above or below the muscle. One criteria for sub muscular placement is having less than 2 cm. pinch of the superior breast, something I rarely encounter except in someone with very small deflated breasts. I am, however, not sure this matters since it is to keep from being able to feel the breast and, in those individuals, the muscle thins so much that it does not really hide the implant. I place the implant sub glandular in 95% of the implants I do and obtain very natural results with almost no problems.

Highlands Plastic Surgeon

Over the muscle implants

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Thanks for your inquiry, you have had a great answers to your question by my colleagues.  My advice is for you to ask your surgeon why he/she is recommending over the muscle?  Let your surgeon explain why not under the muscle.  Good Luck.  

Over or Under the muscle

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In general, the benefits of submuscular breast implant placement are:

  1. Better superior (upper) coverage/hiding the implant in your cleavage where you will show them off the most
  2. Much lower rates of capsular contracture or scar tissue build up around the implant
  3. Most importantly, breast implants under the muscle do not interfere with your mammogram

I do not believe there to be any lasting benefit of subglandular (or sub fascial) placement. If your breasts are entirely below the muscle he will recommend a mastopexy (lift), not subglandular placement, to take advantage of the benefits mentioned above regarding submuscular implants. A submuscular implant looks better, feels softer for longer and doesn’t interfere with mammograms, giving you the best chance at early breast cancer detection and highest cure rate should it develop. However, it’s not always that simple. Many times the bottom edge of the pectoralis major muscle ends higher than your natural breast crease. If the placement of breast implants lies completely under the muscle it “rides high” and delivers a less than ideal aesthetic result, with your natural breast “falling off” the front of the implant. Therefore, to prevent that, I frequently utilizes a dual plane implant placement. This means as much of the upper portion of the submuscular implant is under the muscle, for all the reasons listed above, but a small portion of the implant “peeks” out from under the muscle so the implant is nearly centered under the nipple. There are different degrees of dual plane release (I, II, III) but I also will do as little a release as possible to achieve an optimal aesthetic result, thereby leaving maximum muscle coverage.

Go under the muscle

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looking good after surgery is one thing -- having a good long term result with minimizing interference on mammograms and reducing contracture risk is another. Implants above the muscle are a short term answer. An implant under the muscle will look better longer and stay soft. The recovery is nearly the same. Good luck!

Robert S. Houser, DO
Columbus Plastic Surgeon
5.0 out of 5 stars 17 reviews

SIlicone above the muscle or not.

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There are a few benefits of going above the muscle. They are less initial discomfort, and can help hides some droopiness. Also less movement with pectoral muscle use> But there are far more reasons not to go above the muscle. As for discomfort with under the muscle, it typically is about 1/2 day more of discomfort, that's it. As for hiding droopiness you can get the same effect with dual plane or biplanar sub muscular placement but you gain so much more from being under the muscle. There is more padding when placed below so much less rippling. Not to mention the significantly lower risk of capsular contracture when placed below the muscle. I would encourage that you get a second opinion. I tend to find that the doctors that choose sub muscular are mustly choosing it for their ease of placement not for the patients benefit. Our consults are complimentary and we also offer virtual consults for those from out of state. 

William J. Hedden, MD
Birmingham Plastic Surgeon
4.8 out of 5 stars 334 reviews

Under vs over the muscle

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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

Breast Implants/Breast Augmentation/Anatomic Gummy Bear Implants/ Silicone Implants/Breast Implant Revision Surgery

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I appreciate your question.

The best way to determine implant size is based on chest wall measurements that fit your body.  Once we determine that we can choose the profile based on what you want or need to achieve.  

Implants under the muscle, there is less risk of capsular contracture.  Anatomic implants tend to give a more natural shape with more nipple projection.

The best way to assess and give true advice would be an in-person exam.  Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.

Best of luck!

Dr. Schwartz

Board Certified Plastic Surgeon

Director-Beverly Hills Breast and Body Institute


No significant aesthetic difference in placement above or below the muscle was silicone gel implants.

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If you choose silicone gel implants I don't see any advantage and going below the muscle. The capsular contracture rate is not statistically different above or below. The incidence of contour irregularities with silicone gel is no different either. Placement under the muscle increase the risk for bottoming out


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I think going subglandular or subfascial is a reasonable option - pending the size/shape of the implant. I agree that texturing will reduce the contracture rate. As to mammography - as long as you tell the radiologist/tech that you have subglandular implants they will be able to add additional views for screening to insure that they visualize all the breast.

Asaf Yalif, MD
Roswell Plastic Surgeon

Implant Size

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When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, the #1 most commonly debated issues (here and elsewhere) is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? There are distinct differences to each approach. Surgeons have their preferences and their reasons for the choices they make. Below I will offer you a breakdown (as I see it) of the (+) and (-) to each approach.


Subglandular Augmentation:

         Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster when compared to subpectoral augmentation (instrumentation of the muscle hurts!).


·      Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation (either way). It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).


·      Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space. Some have suggested that placement of a textured implant can mitigate this elevated risk.


·      Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.


Subpectoral Augmentation:

·      Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.


·      Subpectoral implants have a lower rate of capsular contracture.


      Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.


·      The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.


Each approach has both costs and benefits. Patients are unique and so too is each operative plan (and each operating surgeon). A potential augmentation candidate may be better suited for one approach or the other.  As always, your board certified plastic surgeon can help guide you in your decision making process.

Best of luck!

Donovan Rosas, MD
Kissimmee Plastic Surgeon
5.0 out of 5 stars 13 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.