Pros and cons of under vs over the muscle?

Thank you for sharing your excellent question.  For most patients pursuing a breast augmentation a submuscular placement is preferred as it offers a more natural look and feel, reduces the risk of implant rippling, and trends towards fewer complications.  It does come at the risk of animation deformity and a longer recovery.  As far as sizing it is impossible to recommend the best implant style, size or shape without an in-person examination that allows for the measurement of key breast parameters, as well as permits an in-depth discussion as to your desired goals and outcome. It sounds as if it may be wise for you to "try on" several of the implants so that you can have a better visual representation as to what they would look like.  Best wishes!

In most patients there's not a big difference aesthetically and implants above or below the muscle. There are certain circumstances, such as a constricted breast, or placement of the implant above the muscles preferential. At other times when there is a paucity of subcutaneous fat is sub muscular placement might be preferred. In your particular case this should be discussed with your surgeon. From the photographs I think you would be well served implants either above or below the muscle. Because there is less pain and no animation issues you might want to consider sub glandular.

Your question is a very good one, and as you have discovered, plastic surgeons are not in agreement over this issue.  While it is true that implants placed directly under the breast tissue have certain advantages, such as more readily shaping the  breast, and avoid problems such as " double bubble", and implant displacement with exercise, I believe these are outweighed by the disadvantages. Much of the blood supply to the breasts is interrupted when implants are placed on top of the muscle, which can lead to complications when other procedures such as lifts are performed. In patients with little breast tissue and body fat, the implants are more readily felt, and wripplng is a much greater problem with both silicone and saline. I placed implants on top of the muscle frequently earlier in my career, however because of these issues, I rarely do after twenty seven years.

Hello and thank you for your question. Judging from your photographs alone, the short answer is for a natural look and C cup goal, I think you would most benefit from an implant closer to 300cc (than 500cc as you mentioned), UNDER the muscle.
From a general standpoint, your question
does bring up the overall process of ideal breast implant selection which
can be quite involved, as breast augmentation involves a number of different
issues.  The first step would be to clearly define your desired
breast outcome goals – this would include the size you would like to achieve,
and your ideal breast shape.  I would then select the best breast implant
for you based on:


(1)   Volume of the implant –
actual implant sizers that you try on during your consultation can help with
this.  I commonly used the Mentor volume sizing
system for this purpose.


(2)   Contents of the implant –
saline vs silicone, saline tends to be a little stiffer, rounder and can cause
rippling of the skin


(3)   Shape of the implant –
round or anatomic;  I would show you how both round and anatomic can
provide a natural shape


(4)   Position of the implant –
if it is over or under the pectoralis muscle; each location would provide a
different shape and projection.  The
advantage of going “under the muscle” is that it provides a lower risk of capsular
contracture, lower risk of skin rippling, and better visualization on future
mammograms.  Also, many patients describe
the appearance as more natural, and describe the feel as more consistent with
that natural breast.


(5)   Skin stretch of your breast
– younger patients tend to have more taught skin with more… SHOW MORE
resilience, and respond well to an implant; compared to an older breast with
more stretch marks, which would typically requiring a larger volume to fill the
breast


(6)   Degree of breast ptosis
(sagging) – a significant sag would benefit from a breast lift


(7)   Breast diameter and overall
chest circumference


(8)   Native breast tissue volume
– the amount and distribution of the natural breast tissue.


(9)   Any history of prior
surgery or trauma to the breast


The next step for
you is to seek out a board certified plastic surgeon who specializes in
aesthetic plastic surgery.  In your consultation, be sure
your surgeon addresses all your concerns and discusses the surgery details
including the position and size of the incision used (with actual photographs),
the type of breast implants available, the risks and benefits of the procedure,
recovery time, and post-operative course.  Also, be sure to see plenty of
before-and-after pictures in women who have a similar breast appearance to
yours, and preferably at different time frames (3 weeks out, 3 months out, etc)
to more accurately predict your own surgical outcome.


And lastly, I think the most important
component of the consultation is to establish a good connection with your
plastic surgeon.  It’s the connection that allows you to clearly define
your desired breast outcome goals, the first step of this whole process. If you
don’t feel you have a good connection with your plastic surgeon after your
consultation, he/she may not be the best surgeon for you.
For more information on breast augmentation, please refer to the link below.


Good luck.


Mark K Markarian, MD, MSPH


Harvard-trained Board
Certified Aesthetic Plastic Surgeon

Thank you for your question. An in person examination is very important in order to give you a valuable opinion. If this is not possible any doctor would like to see some of your photos in order to have an idea of the conditions of your breast. The laxity of your breast is very important in order to decide all the parameters needed to give you a nice shape. If you have slightly ptotic breast, probably the Dual Plane technique would be the appropriate. Please attach some photos in order to help us. 

I started out my practice putting all of my implants on top of the chest muscle because that was the way my father did it.  His idea was that that was where your breast tissue was and that was where it would look and behave most like breast tissue.  He was right about that, but he got a lot of capsular contractures.  These are thick scar tissue capsules that can form around an implant and contract, causing the breast to feel firm or distort the way it looks.  A lot of doctors feel that capsular contractures form in response to bacteria that live in the breast tissue. When you put the implants below the chest muscle, the muscle forms a barrier between the implants below and the breast tissue above where the bacteria live.  I started putting my implants under the muscle starting around the year 2000 and it has pretty much eliminated capsular contractures with my patients.  There is also some suggestion in the literature that it is easier to perform and to interpret mammograms when implants are below, rather than above, the chest muscle.  I think this may relate to capsular contractures as well.  It is harder to move a firm breast around and visualize the tissue if there is a capsular contracture present.  Going under the muscle has some issues as well.  First, muscle doesn't stretch as easily as breast tissue does and it will take longer to get to your final result.  Still, the final results should be comparable whether the implant is above or below the muscle.  Another issue in placing the implant under the muscle is that it will move along with the muscle which may be somewhat disconcerting.  I haven't had many issues with double bubbles or implants migrating into the armpit although these would be risks of submuscular placement.  Still, I think it is a fairly low risk.  As for questions regarding volume, shape, style, etc of implants to use, this would be a questions to be decided in consultation with a board-certified plastic surgeon who can examine you in person and review your options with you.

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.  This entire surgery can be performed with a
small incision technique.  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.   The
most important aspect is to find a surgeon you are comfortable with. I
recommend that you seek consultation with a qualified board-certified plastic
surgeon who can evaluate you in person.
Best wishes and good luck.
Richard G. Reish, M.D.  FACS
Harvard-trained plastic surgeon

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.
 Subglandular Augmentation (“overs”): 
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 fasterSubglandular 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. 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.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 when compared to subpectoral augmentation.Subglandular implants can also create the illusion of improved cleavage by preferential over-dissection of the central/medial pocket allowing the implants to be forced more to the midline. There is no limiting muscle as there is in a submuscular augmentation. 
Subpectoral Augmentation/Sub-muscular (“unders”): 
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.With regards to your specific question, the muscle will exert a slight downward pressure on the implant upon contraction (in the early stages) and at rest it will serve to flatten the upper pole (eliminating some of the roundness associated with a subglandular augmentation). In my practice, the vast majority of patients have implants placed under the muscle for all the reasons listed above.
As always, discuss your concerns with a board certified plastic surgeon (ABPS)

Thank you for your question.When performing breast augmentation surgery, the most common approach is placing the implant below the muscle. The advantages include having an extra layer of tissue (the muscle) covering the implant, which decreases the possibility of rippling, and decreased palpability of the implant for the same reason. There is also a decreased chance of the implant stretching the breast skin which could lead to an earlier need for a breast lift. If the pocket creation is performed appropriately under the muscle, the chance of a double bubble occurring is minimized.The size implant you choose should be carefully discussed with your board certified plastic surgeon. Based on your wanting to look natural and the pictures you posted, I believe a 500cc implant is to large for the look you are trying to achieve. A 325cc or 350cc implant would be more appropriate.I hope this helps.

Many thanks for your question. If looking natural is the key factor in your breast augmentation, you would be well advised to use the dual-plane approach. This covers the top half of the implant with pec muscle to smooth the junction of the upper breast with the chest wall.You are very slim and the volumes of implant you are considering to attain a C Cup may look fake or have a visible upper edge if placed on top of the muscle. You should try implant sizers of varying sizes in a C cup trial bra in front of a mirror, together with accurate examination and measurement by an experienced plastic surgeon, to judge which implant volume and shape is best for you. Your estimate of 350cc will likely give you a much more natural result than 500cc.Good luck with your treatment.