What are the cosmetic differences in over the muscle vs under the muscle implants?

I am concerned about the pain associated with under the muscle implant procedure, and heard from one of the doctors that I had a consultation with the over the muscle implants are making a come back. My biggest question is what is the difference in the way these two procedures look and feel? Which one is more natural? Are over the muscle implants making a comeback?

Doctor Answers 12

It mostly depends on your body type.

Thin patients with little body fat are generally poor candidates for breast augmentation on top of the muscle.  If you have a little more body fat and/or breast tissue, you have more potential for a good result in that location.

However, underneath the muscle remains the most common position.  In fact, at a recent conference of the largest group of plastic surgeons in the US dedicated to cosmetic surgical procedures, a survey revealed that more than 80% place the implants underneath the muscle >90% of the time.

Furthermore, there are many reasons to still consider going underneath the muscle.  They include critical elements such as less interference with mammograms, and a lower risk of capsular contracture.  Factors such as pain are inconsequential for a delicate surgeon.

Luckily, you are looking for surgery at an unprecedented time in plastic surgery.  The recent advent of new breast implant designs and styles gives us more control over our results and enhances the choices you have for a fabulous outcome.

Best of luck.

Under or Over: Which Is Best?

Submuscular placement of breast implants is typically associated with more discomfort during the recovery period than subglandular placement. That is one factor to consider, but your body type, the amount of natural breast tissue you have, and your skin's thickness all need to be included in the decision-making process, as well. An under-the-muscle placement is usually preferred for women with less natural breast tissue because it typically results in more natural-looking outcomes. Visible rippling and wrinkling can occur with over-the-muscle placement if there isn't enough tissue to camouflage the implants. Think long-term results, rather than short-term discomfort, when making your decision.

Shannon O'Brien, MD
Portland Plastic Surgeon
5.0 out of 5 stars 4 reviews

Over the muscle or under for breast augmentation

This is a great question and one that is frequently debated among surgeons who perform breast augmentation.  I think the answer depends in part on the anatomy of the patient and the implants being used. The advantages of placing the implants above the muscle include a shorter recovery as well as avoiding the possibility of distortion of the results from contraction of the pectoralis muscle. However, in most patients I prefer to place the implants under the muscle.  Sub-pectoral (under the muscle) implant placement decreases the possibility of any visible wrinkling or rippling of the breasts.  It also decreases the risk of implant palpability (being able to feel the implant).  This is especially true in slender women who have minimal breast tissue to begin with.  In addition, studies have shown that putting the implants below the muscle decreases the risk of a complication called capsular contracture.  This is tight scar tissue that makes the breast firm and distorts its shape. Some surgeons feel that nice "cleavage" is difficult to achieve when the implants are placed below the muscle. However, I have found that rarely to be an issue. 
While the vast majority of implants placed today are filled with some type of cohesive gel, saline filled implants should certainly be placed below the muscle due to the high risk of rippling and palpability if they are placed above it. 

Laurence Weider, MD
Dallas Plastic Surgeon
5.0 out of 5 stars 91 reviews

What are the cosmetic differences in over the muscle vs under the muscle implants?

Under the muscle breast implants provide more coverage of the implant and over the long-term under the muscle breast implants look more natural longer.

If you have a large amount of breast tissue to cover the breast implant then under the breast over the muscle implants may be a good option.

Because the new cohesive silicone gel implants have a much lower chance of capsular contracture or hardening many surgeons feel that placing the implant beneath the breast in patients who have adequate breast tissue or have slight sagging and do not want a lift, can be an acceptable option.

DEPENDS ON ANATOMY

In patients with wide cleavage, over the muscle with silicone gel implants will be superior. When the implant is under the muscle, the medial muscle attachments to the chest act as a wall and as the implant size increases the implant is pushed toward the axilla.  In patients with tight cleavage and adiquate breast tissue the difference can be minimal.

The big difference is the jumping breast deformity that occurs when the implant is placed under the muscle.  The inferomedial portion of the muscle that is cut to insert an implant under the muscle, retracts and attaches to the breast tissue. When the muscle contracts, it pulls the breast out instead of pulling the arm in.  This can be minimal or exaggerated and certainly is not natural in any degree.

There are other pros and cons to be considered, but from a purely cosmetic point of view, over the muscle is superior to under the muscle in our 36 year experience.

Luis Villar, MD, FACS
West Palm Beach Plastic Surgeon
4.8 out of 5 stars 9 reviews

Over the muscle look more natural

Natural breast is always in front of muscle. Nobody is born with breast behind the muscle. Thus over the muscle are more natural and similar to natural breast.

Vasdev Rai, MD
Dallas Plastic Surgeon
5.0 out of 5 stars 22 reviews

What are the cosmetic differences in over the muscle vs under the muscle implants?

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 and desired outcome..

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

What are the cosmetic differences in over the muscle vs under the muscle implants?

Thank you for your question.  Under the muscle gives a more a natural look, hides the edges of the implants better, has a lower risk of capsular contracture, less visible rippling and less interference with mammography.  Most BAs are performed under the muscle.  There are some situations where above the muscle may be advantageous, for instance athletic women, where animation deformity is avoided.  Be sure to consult with an experienced board certified plastic surgeon.  Good luck!

Zachary Farris, MD, FACS
Dallas Plastic Surgeon
5.0 out of 5 stars 16 reviews

#Breast implants below or above the muscle

Above the muscle implants will give you a final look earlier than below the muscle, because you do not have to wait for the muscle to relax. For the same reason, it is less painful for the patient. Also it is easier for the surgeon to dissect the pocket, some surgeons, perform the surgery with IV sedation and local anesthesia. All of these are the pros.
The cons:
Because the skin is the only structure that support the implants, specially in bigger implants, they will drop significantly with time, your skin and breast tissue will get even more thin. You need to look at patients after 2 years to see the final results.
The incidence of capsular contracture is higher in above the muscle positioning.
The implant and any problem (like contracture or rippling) are more visible.
In my professional practice, I stopped doing above the muscle implants, about 14 years ago. It is my opinion, that long term results are better with under the muscle positioning.

Victor M. Perez, MD, FACS
Kansas City Plastic Surgeon
5.0 out of 5 stars 23 reviews

What are the cosmetic differences in over the muscle vs under the muscle implants?

Thank you for your question. It all depends on the look you are going for. If you would like a more natural look then under the muscle may be a better choice. Having your implants placed under the muscle also decreases the risk for capsular contracture and other complications. Over the muscle may give you a more rounder look, however, it depends on how much breast tissue you currently have. I would recommend seeing your plastic surgeon again and discussing your concerns/questions with him/her. Hopefully you find something that works for you. 

All the best, 

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 427 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.