Which breast implant location is best for patients who lift weights? I have stretchy skin. I'm 5'3", 137lbs.

Question

So confused between submuscular or sub facial. I'm not a fan of mesh. An implant makes me nervous already, mesh more so. However, I do decent amount of chest exercises with moderately heavy weights. 10-80lbs. (I'm not a body builder) I have stretchy skin. I'm 5'3", 137lbs. Currently 36 A/B depending on bra. breasts are in great shape after breastfeeding 3 kids. They're just smaller. I'm looking at a 215-225cc breast implant. Want to stay pretty small. Thanks!

David Hill, MD · Answer

Choosing between subglandular (above the muscle) and submuscular (below the muscle) breast augmentation involves considering several factors, especially for someone active with chest exercises and with specific aesthetic goals like you have.
Subglandular Placement:
 Pros: The implant is placed directly under the breast tissue but above the pectoral muscle. This method typically offers a shorter recovery time and less pain during the recovery process because it disturbs fewer muscles. Activity Impact: For those who engage in chest workouts, subglandular placement might not interfere much with exercise post-recovery. However, because the implant is closer to the skin, there might be more visible rippling, especially in individuals with less natural breast tissue. Aesthetic: This option can provide a more pronounced cleavage and a more natural movement of the breasts, as the implants are not constrained by the muscle movements.
Submuscular Placement:
 Pros: Implants are placed under the pectoral muscle. This placement can offer a more natural slope of the upper breast and typically has a lower rate of capsular contracture (hardening of the tissue around the implant that can squeeze the implant, distort, or displace it). Activity Impact: For someone who lifts weights, recovery might involve more discomfort and a longer period before returning to full chest workouts. The muscle needs to heal and adjust to the implant. You also have the high risk of animation deformity, where the implants move with any pectoral muscle flexion/movement, which looks unnatural. Aesthetic and Physical Considerations: Submuscular might be preferable for those with less natural breast tissue or those concerned about the palpability and visibility of the implant, as the muscle covers the implant more effectively.
Given your activities and concern about using mesh, as well as your aesthetic goals to remain relatively small in augmentation size, you have some competing interests, and discussing these preferences in detail with your surgeon is crucial. They can offer guidance tailored to your body’s characteristics and your lifestyle, ensuring the chosen placement aligns with your desired outcome and recovery expectations.

Donovan Rosas, MD · Answer

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 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. 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 (“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.

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.

With regards to your specific concerns, I would still favor submuscular placement for all the reasons listed above. I have operated on athletes of all types without issues.

As always, your board certified plastic surgeon (ABPS) can help guide you in your decision making process.

Daniel Barrett, MD · Answer

Dear randomstuff088,
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, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

George Volpe, MD · Answer

This is a controversial question with no real right or wrong answer. There are pros and cons of over the muscle versus under the muscle implants in the should be fully discussed with you by your surgeon. After allowing sufficient time to heal (about 6 weeks) one should be able to resume lifting weights. Over the muscle implant does have the advantage that when contracting the pectoralis muscle the overlying breast does not move as much as it would if a were below the muscle. However under the muscle implants have advantages over long-term looks and the development of capsular contracture. In our practice we have a number of weightlifting and bodybuilding women, including professionals bodybuilders with under the muscle implants (sub muscular) with no change and their activities or amount of weight they can lift. I do agree with the questioner that mesh should not be used unless in certain unique situations that are quite uncommon.

Maryam Zamani (Saheb-Al-Zamani), MD · Answer

This is a great question. In athletic patients, those who lift/ do chest exercises, or have strong chest (pec) muscles, placement of the implant under the muscle can result in animation deformity (movement of the implants/ breasts with chest muscle use). This can give the appearance of "jumping breasts" in the gym and over time potentially risk implants being pushed too high/ too low/ or too much to the side. For this reason, if a patient desires implants under the muscle or requires this placement because they are too thin, I advise them to adapt their activities to minimize the development and use of the chest/ pec muscle. Alternatively,  the implant can be placed subfascial (under a thin casing layer over the muscle) which gives the implant some of the benefits of being under the muscle such as stability but without any risk of movement of the implant/breast with chest/ muscle flexion. As with regards to size, small or large implant sizes can be placed subfascial. I recommend that you consult with a board-certified plastic surgeon to discuss your goals and desires.
Dr. Zamani

Tyler Frew, MD · Answer

Hi there,
There is truly no perfect spot for the implant but both places have pros and cons.
The most important thing about going above the muscle is to be sure your tissues are thick enough to camouflage the implant, otherwise you will get rippling and need them revised. If you work your chest out a lot and have thick enough tissues then going above the muscle makes sense.
You need to be seen and examined in person so the doc can determine your thickness and let you know if you are a candidate. If you are not then you should do under the muscle without too much worry or hesitation. 
As to mesh, all of the breast meshes are dissolvable/broken down by the body in about 1-2 years. they leave behind a thicker layer of scar tissues to help support the implant and hold your results for longer.
All the best

Gianfranco Frojo, MD · Answer

I always recommend submuscular through an inframammary (breast fold) approach, as there is lower problems with capsular contracture. I would recommend seeing a surgeon certified by the American Board of Plastic Surgery.

Wayne I. Yamahata, MD · Answer

I would favor placing the implants under the muscle. Although you have not posted photos, I suspect that you would benefit aesthetically from the extra coverage. In addition, this location improves mammography. Woman who are athletic and excise aggressively may see some animation, but this is a small tradeoff for the overall benefits.

Gerald Minniti, MD, FACS · Answer

There are tens of thousands of highly active patients who have their implants in the subpectoral position. Good data accrued over decades reveals that this implant position is the safest with regards to capsular contracture, implant palpability, and rippling seen in the upper and medial aspects of the breast. Subfascial placement has no good evidence to support its superiority over the subglandular position. Although there are a few case reports from surgeons, this is not good data because of biases. Only randomized trials can tell us the truth. Stick with submuscular, which does not necessitate mesh. What does necessitate mesh is anatomical evidence of poor soft tissue support, either due to weight gain or lactation that has stretched out the breast tissue.

Ronald J. Edelson, MD · Answer

I still prefer placing the implants under the muscle. Subfascial to me is a vague term. And you don’t  need mesh. Mesh is a trend now but I think is overused

Which breast implant location is best for patients who lift weights? I have stretchy skin. I'm 5'3", 137lbs.

Answers (16)

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