Is it better to have implant under muscle or over muscle?

Doctor Answers 24

Above or below the muscle for breast implants

Obviously there is no one "right" place to put a breast implant and not even any agreement among surgeons as to the "best" place. Unlike many surgeons, I feel that in general for most women on top of the muscle gives a more natural appearance. After all, the breast tissue we are trying to increase is above the muscle and I feel an implant above the muscle behaves and moves more naturally than one below it. I also feel that there is a different look for implants placed under the muscle and many of my patients don't like that look. And each surgeon has different experience and facility with different techniques. You need to discuss with your board certified surgeon what your goals are and how best they can be accomplished. You need to be comfortable with the plan that you and your surgeon come up with for you. Good luck.


Sacramento Plastic Surgeon
3.5 out of 5 stars 13 reviews

Breast Implants - Above or Below the Muscle?

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
5.0 out of 5 stars 108 reviews

Is it better to have implant under muscle or over muscle?

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!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 20 reviews

Is it better to have implant under muscle or over 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 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.   
Best wishes.

Depends on your body

There is no single approach that is ideal for every patient. Your surgeon will help you decide which implant pocket placement is best for you prior to surgery, taking special care to select one that will achieve your personal goals and expectations.

Over or under muscle (breast aug) and why?

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.

Implant better under or over the muslce

if you are a candidate for under the muscle, I feel that is a better choice as the chances of capsular contracture are less. A little longer to get to the final result versus above the muscle but I feel it is worth it.

Julio Garcia, MD
Las Vegas Plastic Surgeon
4.5 out of 5 stars 16 reviews

Above or Under the Muscle

In the vast majority of cases, I would prefer to place breast implants underneath the muscle for the primary reason that there is a significant increase in capsular contracture or breast hardness with implants on top of the muscle.  Submuscular coverage  gives more soft tissue coverage of the implants and in many cases makes mammography easier. Yes there may be a bit more post operative pain but with early stretching this can be decreased and long term, I think patients do better. This is my preference, others may have a different approach.

Richard Linderman, MD
Indianapolis Plastic Surgeon
5.0 out of 5 stars 9 reviews

Better To Place Implant Below Muscle In Most Women

It is almost always preferable to place implants below the pectoral muscles if one is seeking a naturally appearing and feeling breast.  Silicone implants also provide these qualities more frequently than saline implants.  There is a bit more discomfort with submuscular implants but it is usually worth it.

John Whitt, MD (retired)
Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Breast Implants - Above or Below the Muscle?

There is no simple answer to this question and it definitely depends on the individual patient.  In general, under the muscle is the more common pocket position in the United States.  The benefits include better coverage of the implant at the top and in the cleavage area.  Additionally, mammogram is less impaired and reports seem to suggest a lower amount of capsular contracture (hardening around the implant).  The drawbacks are that the initial surgery is more painful, there is a certain amount of motion of the breast implant and thus breast with contraction of the muscle and the implant and breast age differently rather than in unison.  The above the muscle plane may either be the traditional subglandular or the more recently described subfascial plane.  When I put an implant above the muscle, I prefer the subfascial plane which means that the thick coating over the muscle is elevated up with the breast tissue.  This gives extra coverage of the implant and towrd the top and inside, I will actually raise up muscle fibers with the dissection to have even additional partial muscle coverage in the area that needs it the most.

Kent V. Hasen, MD
Naples Plastic Surgeon
4.5 out of 5 stars 50 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.