Under Muscle Breast Augmentation for Tight Pectorals?

Question

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?

Otto Joseph Placik, MD · Answer

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

Lewis Albert Andres, MD · Answer

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!

Richard J. Bruneteau, MD · Answer

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.

Rod J. Rohrich, MD · Answer

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.

David Shafer, MD, FACS · Answer

RedGirl122,
It is okay to have your implants above the muscle.  If they are put under the muscle, the muscle needs to be cut in order to accommodate the implant.  However, if you are an athlete, then you may prefer to the have the implant placed above the muscle.  Just find a plastic surgeon who is comfortable doing this procedure.  Good luck.

Richard Baxter, MD · Answer

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.

Armando Soto, MD, FACS · Answer

Hi there,
Because of your very active lifestyle, I would agree with my colleagues that you are probably best served by implant placement on top of your pectoralis.

Remus Repta, MD · Answer

Hello,

	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

Michael Law, MD · Answer

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

Steven Wallach, MD · Answer

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.

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