Under Muscle Breast Augmentation for Tight Pectorals?

I'd like to enhance my breasts and am looking at the options.  I am a fitness competitor and trainer and I worry about the effects of under the muscle implant placement. I have a tendency toward very tight pectorals which has resulted in some issues with my training. I am a full B cup (small C depending on the bra). I would like to go up, maybe a little more than one cup, but less than two. My sister recently got implants and her doctor does not even offer over the muscle procedure. Is this a standard in Breast Augmentation now? It seems like everything I read leans toward under the muscle. Would "unders" be an option for me with my training concerns and chronically tight pectorals?

Doctor Answers 20

Breast Augmentation for Bodybuilders - Professional Athletes, and Fitmess Models

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I regularly perform breast augmentation surgery for patients who participate in body building, fitness and figure competitions. While many are initially concerned about sub-pectoral placement and the potential for distortion of the appearance of augmented breasts when the pec major contracts, I am absolutely confident that the aesthetic outcome for these patients will be far superior with implants placed under the muscle.

A pre-pectoral implant in a slender patient, especially one with well-developed muscles, looks just as you imagine it would: like a foreign object, not like a natural-appearing breast. The muscle does not have to contract for a pre-pectoral implant to look unnatural in this group of patients - it looks unnatural every minute of the day.

Achieving the ideal aesthetic position for a sub-pectoral implant requires release of part of the inferior origin of the muscle from the chest wall. I perform the minimal release of the origin of the pec major that is required to get the implant in an ideal position vertically, but also weaken the origin in the area where muscle contraction tends to displace an implant. As a result the vast majority of patients have little to no distortion of their breast appearance when the pec major muscles are tensed. Patients also do not experience any loss of function, strength or range of motion from release of this very limited part of the pec major origin. Many patients have indicated that their natural (but augmented) breast appearance has provided a significant 

Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Consider subfascial implant placement

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Your situation is actually common but one that requires special consideration. Traditionally, under the muscle is recommended for better coverage of the implant and more natural contours. However, athletes such as yourself are usually advised to have them over the muscle, because of the tightness of the muscle and the potential for what are called animation deformities (which is distortion of the breast with physical activity). But going over may mean that coverage isn't good because of low body fat. A good compromise is something called subfascial or split subpectoral/subfascial.

I became interested in this technique about 6 years ago specifically for athletic patients.

Consider above the muscle silicone implants

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Hello Jessica,

Your concerns are very valid. We prefer under the muscle (partial submuscular, dual-plane) placement for the vast majority of our patients, including fitness instructors. However, when a woman's pectoralis muscle is very thick and tight (as in body builders), we have chosen to go above the muscle using silicone implants of a higher profile.

I have seen "unnatural" results with both above the muscle and under the muscle approaches, so one approach does not guarantee a natural appearance. There are pluses and minuses to any approach and you should carefully discuss both approaches with your doctor. If he/she only offers one approach, get an opinion from someone who does offer both approaches and speak to women who have had above the muscle as well as below the muscle implants.

In women who have large, but no overdeceloped muscles (firefighters, landscapers), we have been successful in under the muscle placement. It does take a bit longer for the result to reach its final shape and it does look less natural for the first month as the large muscle bulges more up top. However, our patients have been happy and have not noted any loss of measurable strength.

Our bodybuilders have also been happy with their above the muscle approach, so it is a matter of knowing your expectations, discussing it at length with your doctor and speaking to a few patients from each category. Good luck.

Dr. Canales

Under Muscle Breast Augmentation for Tight Pectorals?

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Hello! Thank you for your question! Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts. Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years. In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance. Your breast width is the most important measurement.

Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant. This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape. Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width. Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later. Very slightly less tissue may be visualized with subglandular implants, but not very significant.

Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle). Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each. In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome. A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles. Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions. As you see, there are a few factors to decide upon for incision, placement, and implant type/size. Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits.

Hope that this helps! Best wishes for a wonderful result!

Subglandular Should Be Consideration

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It’s not unusual for female body builders to be concerned about the appearance of their breasts. For this reason, they often request breast augmentation surgery.
Surgery in this group can be challenging for a variety of reasons. These patients often have large thick pectorals muscles that have the potential to distort the underlying breast implant when they contract. This problem is often accentuated by minimal subcutaneous and breast tissue.
It’s important to realize that each patient is unique and, for this reason, treatment needs to be individualized. In the vast majority of female body builders, submuscular breast augmentation is the treatment of choice but it’s also important to realize that exceptions do exist.
In patients who express concern about implant flattening because of contractions of their pectoralis muscles or patients who are concerned about animation deformities, subglandular placement is definitely a consideration.
Female body builders should consult a board certified plastic surgeon and thoroughly discuss these issues. Based on these discussions, a treatment plan can be formulated that addresses unique anatomic considerations and hopefully, achieve the patient’s aesthetic goals.

Breast Augmentation in a Fitness Competitor or Trainer

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In general, most of the time I use saline or silicone gel implants below the muscle because they have a tendency to look and feel better and mammograms are easier to perform. However, in patients who are fitness competitors and trainers, I use a subglandular breast augmentation with a silicone gel implant because of the fact that most of these patients are lean, have minimal amount of breast tissue, and don’t want their implants to move during these fitness competitions.

Rod J. Rohrich, MD
Dallas Plastic Surgeon

Under the muscle vs over the muscle breast augmentation

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A breast implant can be placed under the muscle, on top of the muscle under the cover of he muscle (subfascial), or over the muscle under the breast gland.  In general, saline implants should be placed under the muscle.  Some patients with very thick breast tissue may be ok with saline on top of the muscle but in general saline implants should be placed under the muscle.  Silicone implants can be placed under or over the muscle.  Very thin patients and patients that have a lot of breast laxity (ie. after multiple children or massive weight loss) should also go under the muscle with silicone.  Every one else can get silicone either under or over the muscle. The benefits of going on top of the muscle is that the pocket is not determined by the muscle connections, recovery is faster, the breast feel softer, and there is no animation (breast movement with muscle contraction)

All the best,

Dr Repta


Remus Repta, MD
Scottsdale Plastic Surgeon
4.9 out of 5 stars 170 reviews

VIDEO: Dynamic animation deformity with well defined pectoralis

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individuals with well developed pectoralis muscles tend to prefer over the muscle placement which can make the implants more visible. If placed under it is more likely to result in the dynamic animation deformity: see attached video

Implants in trainers

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Tight or not the implants can go under the pectoralis msucles.  These are usually cut to accomodate the implants along the inferomedial aspect.  But, they might move funny especially in a weight trainer. You may want to consider above the msucle if you have enought soft tissue to cover them.

There are trade-offs in implant techniques

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In general, body builders and fitness trainers opt for implants over the muscle (subgalndular). When you contract the muscle a lot, it distorts the implants. Placing the implants under the muscle also requires cutting and dissecting muscle that may alter your normal anatomy when you pose.

If you have a significant amount of normal breast tissue (large B/ small C) then you may be able to effectively hide your implants behind your breast tissue making for a very natural result without the problems of rippling and excessive show of the implants that plagues subglandular placement in patients with a paucity of breast tissue. The breast will move more naturally since the implants will be located where the breast gland normally is located rather than under the muscle.

The trade-off is a higher risk of hardening with silicone gel implants compared to under the muscle technique. If the implants get hard, then mammograms are more difficult to obtain. There is also a risk of the silicone gel leaking into the gland itself if the bag ruptures and the leak becomes extra-capsular or migrates outside the capsule. In the end, you have to prioritize your desires and your acceptance of certain risks and side effects.

Robin T.W. Yuan, MD
Beverly Hills Plastic Surgeon

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.