Over or under the muscle?

I am 5'2 and 115 lbs and am going to get a breast augmentation in a few weeks and am concerned about over or under the muscle. I am now a b cup and would like a pretty full d as my post surgery outcome. I chose to get silicone gel and my doctor and I decided on about 371 cc. Is that big enough for what I want? My doctor also is urging that I go over the muscle and most people I know suggest under so I'm very confused.

Doctor Answers 7

Breast Implants over or under the muscle

For a thin person with little breast tissue who wants a large implant under the muscle provides more coverage and is recommended. Usually implants 400cc and larger sre required for a D cup in most bra brands (Victoria Secret might be a D with 371.

The only reason for over muscle would be if you have sagging and do not want a lift or if your chest muscle inserts high on the 4th rib.

Under, under, under

Subglandular silicone implant placement is the historical approach to this surgery, and was widely used in the 1960's. The implant edges are more visible, the risk of rippling is higher, the implant is in contact with the non-sterile breast tissue so the risk of infection and capsular contracture is higher. The interface between the breast tissue and the muscle is blurred so the implant interferes with mammography more than sub muscular placement. The blood supply surrounding the implant is worse so the risk of capsular contracture is higher. The support for the implant is less so there is more long term shape abnormalities and sagging. The look of a sub glandular implant is much less appealing than a sub muscular implant. The placement of sub glandular implants makes any subsequent revision surgeries more complicated and less successful. There are no advantages to sub glandular implant placement.

There are many advantages to sub muscular dual plane placement and very many disadvantages to sub glandular placement. I would see no indication to do anything but sub muscular. However, the shape of your breast would require a surgeon that is specifically experienced in the treatment of ptosis with implants. This can be best accomplished with the armpit approach. The most sophisticated approach to breast augmentation is through the armpit with a surgical camera (transaxillary endoscopic). Using this modern approach the space can be crafted under direct vision, with virtually no bleeding and no postoperative bruising. Most importantly, the shape of the breast is meticulously created. The other, older methods of insertion are technologically less advanced. Both silicone and saline implants can be placed through the armpit by a surgeon with skill and experience using this approach. The incision in the crease is the oldest method of placing the implants and puts a scar directly on the breast.

Gary Lawton, MD, FACS
San Antonio Plastic Surgeon
4.9 out of 5 stars 135 reviews

Over or under the muscle?

There are two choices for breast implant placement: sub-glandular (under the breast tissue and in front of the chest muscle – the pectoralis muscle) or sub-muscular (under or partially under the chest muscle). The best location depends on many factors including: tissue thickness, weight, desired outcome, and individual anatomy. Each position has advantages and disadvantages:

Subglandular implant benefits:
A shorter recovery time.
Less discomfort initially.
No distortion of the breast when the pectoralis muscle flexes.
Mild preoperative sagging can be improved, especially if no breast lifting procedure is performed.
Easier surgical procedure.
Larger implants can be placed.

Subglandular implant disadvantages:
The implant may be more visible.
More visible rippling, especially in patients with a small amount of natural breast tissue.
Generally, saline implants do not produce a good result in front of the muscle.
Higher incidence of capsular contraction.
“Bottoming out” in some patients.
Some radiologists have more problems reading a mammogram with an implant in front of the muscle.

Submuscular implant benefits:
Usually results in a better appearance for naturally small breasted women
Less tendency for seeing ripples of the implant.
A more natural feel to the breast especially in slender women who don’t have much of their own breast tissue.
Less interference with mammograms, although most radiologists take additional views no matter where the implants are placed.
Lower rate of capsular contraction.
Less of a chance of “bottoming out” where the implant bulges at the lower aspect of the breast and the nipple and areolas tend to appear excessively elevated.

Submuscular implant disadvantages:
Recovery usually takes a little longer and is more uncomfortable initially.
There may be an “animation deformity”, which is a temporary distortion of the breasts when the pectoralis muscle is flexed. Body builders and weight lifters generally prefer implants in front of the muscle.
It is harder to achieve cleavage in women who have widely spaced breasts.
The implants often ride higher on the chest.

Actually, most patients who have breast augmentations today have breast implants placed in a combination or “dual plane” position. This approach has the same benefits and disadvantages of a total “submuscular implant”, but with a lesser tendency to ride high on the chest wall. The disadvantage as compared to a total “submuscular implant” is a higher tendency for bottoming out.

The ideal placement in any particular patient depends on their particular anatomy and understanding of the pros and cons of each approach.

Keep in mind, that following the advice from a surgeon on this or any other website who proposes to tell you what to do based on two dimensional photos without examining you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of each operative procedure may not be in your best interest. I would suggest you find a plastic surgeon certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person.

Robert Singer, MD FACS

La Jolla, California

Robert Singer, MD
La Jolla Plastic Surgeon
4.6 out of 5 stars 19 reviews

Submuscular vs subglandular

For my breast augmentation patients, placing breast implants beneath the pectoral muscle and the fascia (dual plane) offers the following 3 major advantages:

1) Decreased rate of capsule contracture
2) More tissue to cover the implant to prevent the implant from being easily seen or felt
3) Support of the breast gland by the underlying muscle to diminish future droop

Capsule contracture is the term used to describe the formation of scar tissue around the implant which, when thickened, can make the implant feel hard and round. Although the implant itself remains soft, the scar tissue "squeezes" the implant, which makes the implant itself feel hard. In the submuscular position, the rate of capsule contracture is decreased in general from 15% to 3%. That's a significant difference.

"Rippling" occurs when the implant shell is easily felt beneath the skin. With subglandular augmentation, the possibility of this occurring is greater than with the submuscular position. Large studies have shown that the chance of "rippling" is 3 times greater with subglandular augmentation than with submuscular augmentation. Additionally, when implants are placed in the submuscular position "there is the important added advantage of improved mammography."

Separating the breast gland from the underlying muscle removes one of the breast "supports." This can lead to accelerated breast droop. Also, by removing the blood supply from the undersurface of the breast, a future breast lift will be more difficult if needed.

The advantage of the subglandular placement versus submuscular placement is that the postoperative recovery is lengthened and the patient may experience more postoperative discomfort. In addition, there may be more motion of the implant with forceful pectoral contracture.

All things considered, the submuscular placement of an implant is the least at risk for the complications of capsule contracture, "rippling" and breast droop.

William R. Burden, MD, FACS
Pensacola Plastic Surgeon
4.9 out of 5 stars 112 reviews

Over or under the muscle?

It is difficult to advise you without the advantage of an in person consultation.  In most patients, I prefer to place the implant under the muscle. 

My suggestion is to have another consultation with your PS and have the discussion again.

Joseph W. Aguiar, MD
Tampa Plastic Surgeon
5.0 out of 5 stars 7 reviews

Over or under the muscle?

Thank you for the question. Generally speaking, I think that it is in most patients best interest to have breast implants placed in the sub muscular (dual plane) position. You will find lots of information about the pros/cons associate with different breast implant positioning on this website.

Otherwise, unfortunately, online consultants will not be able to provide you with specific enough advice (regarding specific breast implant size/profile) to be truly helpful. Generally speaking, the best online advice I can give to ladies who are considering breast augmentation surgery (regarding breast implant type/size/profile selection) is:

1. Concentrate on choosing your plastic surgeon carefully. Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you are looking for. Ask to see lots of examples of his/her work.

2. Have a full discussion and communication regarding your desired goals with your plastic surgeon. This communication will be critical in determining breast implant size/type/profile will most likely help achieve your goals.

In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. In bra sizers can be useful communication tools also. For example, I have found that the use of words such as “natural” or "pretty full D cup" etc means different things to different people and therefore prove unhelpful.

Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup size may also be inaccurate. The use of computer imaging may be very helpful during the communication process.

3. Once you feel you have communicated your goals clearly, allow your plastic surgeon to use his/her years of experience/judgment to choose the breast implant size/profile that will best meet your goals. Again, in my practice, this decision is usually made during surgery ( after the use of temporary intraoperative sizers).

I hope this, and the attached link (dedicated to breast augmentation surgery concerns), helps. Best wishes for an outcome that you will be very pleased with.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,486 reviews

Over or under the muscle

Thank you for your question.  An in-peson exam would be very helpful to assess the thickness of your upper breast tissues and the base width of your breast.  From your description, you sound thin so I am going to assume that you may be borderline with regard to thickness of upper breast tissue.  In my practice, I would avoid placing implants over the muscle in someone very thin, who has an upper pole pinch thickness less than 2-3 cm (about 1 inch).  If there is not adequate tissue coverage, you will be at higher risk for visible wrinkling in the upper portion of your breast.  With regard to size, you may do well with a 371cc implant on your small frame.  It is hard to always predict a cup size because bras vary so much between companies.  If you are uncomfortable with the surgical plan, I suggest you get another opinion from another board certified plastic surgeon.  Good luck. 

Matthew H. Steele, MD
Sioux City Plastic Surgeon
5.0 out of 5 stars 85 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.