How do I Decide Whether to Go Under the Muscle or Over? (Photos)

Hello. I am hoping to travel to Thailand in December and get a breast augmentation. However I am torn deciding whether to go under muscle or over muscle. I like to exercise and i have heard bad things about exercising with implants under the muscle. I am hoping to go from a full A to a full C / small D cup using cohesive gel mentors. Breast feeding isn't massively important to me, but nipple sensation is. Whilst I do want them to look relatively natural i don't mind them looking full and round

Doctor Answers 13

Under or over the muscle?

You don't decide, that's your surgeon's job. Each surgeon recommends what works best in his hands. I would recommend under the muscle for you. Exercise is not a problem. I have placed them under the muscle in professional female body builders. I have also been to Bangkok and observed surgery there. I was very impressed. The surgeons I observed were trained in the U.S, , were Board Certified in the U.S and the hospital was every bit as good as any in the U.S.  But I am sure there are some poorly trained surgeons there also. Make sure you go to a U.S. Board Certtified Plastic Surgeon. They'll show you their credentials if they have them. Ask to see them.   Dr Foster,  Lake Tahoe Plastic Surgery     

Sacramento Plastic Surgeon
3.3 out of 5 stars 15 reviews

How do I Decide Whether to Go Under the Muscle or Over? (Photos)

My question is why travel for the operation? From my view you are better submuscular placed implants. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.6 out of 5 stars 173 reviews

How do I decide whether to go over or under the muscle with implants?

The main reason for placing implants under the muscle has been to provide additional thickness of tissue to camouflage the upper edge of the implant and to hide potential wrinkles or ripples of the implant from being visible in the upper pole of the breast. As it turns out, the risk of capsular contracture (scar tissue squeezing the implant) appears to be significantly lower when the implant is under the muscle, and most radiologists would say that the implant interferes less with mammograms if it is under the muscle. For these reasons, and primarily the camouflage advantage, most surgeons place the overwhelming majority of implants under the muscle. If your tissue is thick enough that going under the muscle for camouflage is not required, then you have to decide whether the other advantages are important to you.

The disadvantages are some additional soreness during the first few days, most surgeons would restrict you from forcefully using your pectoralis muscle while exercising for several weeks, and there is mild distortion of breast shape with pectoralis muscle contraction which is usually only visible when your clothes are off.

Robert M. Grenley, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 87 reviews

International surgery

I generally recommend under the muscle unless the woman is a high performing athlete who needs every fiber of their pecs to perform at a high level. Most us don't fall into that category. Under muscle provides more stable, thicker coverage over implant and has a smaller rate of capsular contracture. Also think twice about going to Thailand for surgery. Who will take care of you if you develop a huge infection back in the US? Don't shortchange the value of safety.

Raj S. Ambay, MD
Tampa Plastic Surgeon
4.3 out of 5 stars 34 reviews

Implants under the muscle are best

Based on your photographs, you appear to be an excellent candidate for breast augmentation.  There are multiple advantages of implants under the muscle and few disadvantages. Advantages include more natural tissue to cover up the implant so you have a better chance of having a more natural look and feel, lower risk of rippling, lower risk of capsular contracture, they get in the way less when getting a mammogram, they tend to sag less in the long run and they cause fewer problems in the future if some day you need a breast lift.  The disadvantages are maybe a little more pain with surgery and the implants will move a little when you flex your chest muscles when you exercise.  In my opinion, the advantages far out-weight the disadvantages.

James McMahan, MD
Columbus Plastic Surgeon
4.8 out of 5 stars 38 reviews

Over vs. Under the muscle implant placement

I believe you will have a nice result with either placement.  However, I do recommend submuscular placement when possible to my patients as there is less chance of capsular contracture.  

Jeffrey Hartog, MD
Orlando Plastic Surgeon
4.5 out of 5 stars 60 reviews

Placement of breast implants

Thank you for a very well-formed question with sufficient details to help us. My recommendation will be to go in a subglandular plane as you seem to have enough breast tissue cover to mask the edges of the implant. This will have the added advantage of not having to worry about the effect of exercising on the appearance of the implant.

I am somewhat surprised at your decision to go to Thailand though....

Anindya Lahiri, FRCS (Plast)
Birmingham Plastic Surgeon
4.8 out of 5 stars 32 reviews

Breast implant position

Thank you for the question and pictures.

There are many more advantages to sub muscular in some breast augmentation than subglandular breast augmentation.

An even more important decision is your choice of surgeon which makes your decision to  “travel to Thailand"  a curious one. I would suggest considering the pros and cons of this decision thoroughly.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,488 reviews

Breast Implant Placement

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
4.8 out of 5 stars 118 reviews

Under or over the muscle for BA?

Based on your photos I think you will get a great result with either. I would recommend under the muscle since I believe that there is less of a capsule contracture throughout your life, not just in the first year or two after surgery.  If done well you shouldn't have any problems with exercise.

Ronald Schuster, MD
Baltimore Plastic Surgeon
4.9 out of 5 stars 77 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.