What are the benefits of either over or under the muscle? (Photo)

I have a consultation in November with dr Muskett and I am obsessing over size. I'm 5'9 160lbs breast fed one baby 34b initially I wanted 600+ cc but I realize the surgeon I'm going to tends to be more conservative. I'm hoping to have 500cc high profile because I like the look of upper fullness. If my body can not accommodate a large silicone implant below the muscle, is a larger size then doable by going over the muscle? What are some risks and benefits to over the muscle?

Doctor Answers 11

Breast implant location

Advantages of having a breast implant placed under the pectoral muscle include lower risk of capsular contracuture, easier interpretation of mammograms, easier to breast feed and more natural look . There are not many advantages to having an implant on top of the muscle (subglandular) other than decreased pain right after surgery. Discuss this in detail with your surgeon at the time of your consultation.

Best wishes,


Beverly Hills Plastic Surgeon
4.9 out of 5 stars 377 reviews

What are the benefits of either over or under the muscle? (Photo)

Benefits of subglandular - better superior breast fullness, better cleavage and the ability for you to have larger implants.  I use this placement, mainly for women who are a little heavier and have some breast tissue.

Benefits of submuscular - more coverage of the upper part of the implant for thin, flat breasted women.  Slightly less risk of capsular contracture.  Discuss with your PS your options

Christopher Costanzo, MD
Thousand Oaks Plastic Surgeon
5.0 out of 5 stars 39 reviews

Breast Augmentation Preop Stress

Couple of thoughts for you. 

1. My cell battery is always in the red too. Kindred spirits! 

2. Your wish pick is 5'8'' 116 according to the web. So good choice in terms of height. She certainly has breast implants, but I would be surprised to learn they were >500cc. 

3. 600+ is a bad idea for anyone. Even if you have a good result initially, the weight and size of the implant will do irreversible damage to your breast tissue. You will have thin skin, atrophied breast tissue and significant droop. 

4. Below the muscle or dual plane (for the most part these terms are synonyms) has several advantages: easier to read mammograms, more natural upper pole, and decreased capsular contracture. Cap Con is the biggest factor for me. The rates are approximately: 1/20 women below the muscle compared to 1/5 women above the muscle. 

5. I would imagine your doc does some kind of preoperative sizing with his patients. Go back in and convince yourself that you are choosing the right size!

Best of luck!

Bradley A. Hubbard, MD
Dallas Plastic Surgeon
5.0 out of 5 stars 125 reviews

Implant options

Thank you for your interesting question. 

Submuscular versus sub glandular implant placement is a very common question and important consideration with breast augmentation.   Some very good answers with good facts have been provided regarding the advantages and disadvantage about the techniques. I will not repeat these facts but will merely comment that most women will do best with submuscular placement and muscle release tailored to their specific anatomy. 

Nevertheless, it is important that you consult with an experienced board-certified plastic surgeon and undergo a thorough examination with thorough discussion to determine which will be best given your anatomy, goals, and lifestyle. Furthermore, it is also very important that you utilize these aspects of a comprehensive consultation to also determine what would be the best size for you. This will include important measurements as well as trying on Sizer's. Best of luck.

Justin M. Jones, MD
Oklahoma City Plastic Surgeon
4.9 out of 5 stars 43 reviews

Over vs under

Thank you for your question.  There are several advantages/disadvantages to each pocket.   The specifics are best discussed in person because your unique physical characteristics can be taken into consideration.   Implants placed under the muscle have more tissue covering them, which can help decrease the risk of visible rippling.  Implants above the muscle may help to "perk up" nipples that are sitting low on the breasts.  There are other potential pros and cons of the two pockets but I would suggest discussing this in person with your surgeon.

William Andrade, MD
Toronto Plastic Surgeon
5.0 out of 5 stars 62 reviews

Under the muscle

Hello and thank you for your question. Implants placed under the muscle have a lower risk for capsular contracture and less rippling.  Most patients find that submuscular implants also look and feel more natural than implants placed over the muscle.  The size 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. 

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Richard G. Reish, MD
New York Plastic Surgeon
5.0 out of 5 stars 124 reviews

Over or under the muscle breast augmentation

  • The main benefit to going under the muscle is better coverage of the implant in the superior pole so you don't see the edge of the implant. Having fullness in the upper pole is very desirable for some women...this is not the same as seeing the edge of the implant.  Given your current size and goal of going large it is likely going to provide a prettier result.
  • Dr Rodger Shortt is a plastic surgeon in Oakville who cares for patients from Oakville, Toronto, Mississauga, Hamilton, Burlington, Georgetown, Milton and the GTA.  He strives to be the best plastic surgeon and is one of the few plastic surgeons in Canada with 5-star ratings on RealSelf, RateMD and Ontario Doctor Review.  He is the director of cosmetic surgery training and an assistant clinical professor at McMaster University.

Rodger Shortt, FRCSC
Toronto Plastic Surgeon
4.9 out of 5 stars 65 reviews

What are the benefits of either over or under the muscle?

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. Best of Luck.

Evan Feldman, MD, FACS
Texas Plastic Surgeon
5.0 out of 5 stars 86 reviews

What are the benefits of either over or under the muscle?

 Thank you for the question. There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”.    I will try to outline some of the differences here;  you may find the attached link helpful as well.

I think it is in the best interests of most patients (including athletes) seeking breast augmentation surgery to have implants placed in the “dual plane” or sub muscular position.  This positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look  of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability  of the implants (which may increase with time, weight loss, and/or post-pregnancy changes). The submuscular positioning  also tends to interfere with mammography less so than breast implants in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position. 

On the other hand,  sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants  seen with flexion of the  pectoralis major muscle)  they can be seen with breast implants placed in these sub muscular position.    


Generally speaking, the best online advice I can give to ladies who are considering breast augmentation surgery ( regarding breast implant size/profile selection) is:

1. Concentrate on choosing your plastic surgeon carefully. Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you are looking for. Ask to see lots of examples of his/her work.

2. Have a full discussion and communication regarding your desired goals with your plastic surgeon. This communication will be critical in determining breast implant size/type/profile will most likely help achieve your goals. 

In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. For example, I have found that the use of words such as “natural” or "upper fulness" or "C or D cup" etc means different things to different people and therefore prove unhelpful.

Also, as you know, cup size varies depending on him who makes the bra; therefore, discussing desired cup size may also be inaccurate. Again, the use of computer imaging has been very helpful during the communication process, in our practice.

3. Once you feel you have communicated your goals clearly, allow your plastic surgeon to use his/her years of experience/judgment to choose the breast implant size/profile that will best meet your goals. Again, in my practice, this decision is usually made during surgery, after the use of temporary intraoperative sizers.

I hope this (and the attached link, dedicated to breast augmentation surgery concerns) helps. Best wishes for an outcome that you will be very pleased with. 

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,487 reviews

Over/Under...The Debate continues

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? This is a question which I see posted here and elsewhere with routine regularity. While many surgeons recommend sub muscular placement, there are distinct differences to each approach.


Subglandular Augmentation/Under the gland/Over the muscle:

·      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.


·      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. 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 (see the second photo). 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/Under the muscle:

 ·      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. 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.

Donovan Rosas, MD
Kissimmee Plastic Surgeon
5.0 out of 5 stars 9 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.