How to Decide Wheather to Have the Implant Under the Muscle or on Top?

Doctor Answers 10

How to Decide Wheather to Have the Implant Under the Muscle or on Top?

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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”. The vast majority of breast implants placed in the "sub muscular" position are really being placed in the "dual plane" position ( partially sub muscular, partially sub glandular).
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 the sub muscular position.
I hope this, and the attached link, helps. Best wishes.

Implant position

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I usually place implants under the muscle because I find that most of my patients are very thin and could use the extra soft tissue coveragge in the superior pole.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Implants over or under the muscle

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This is a hotly debated question and there is no right or wrong answer. Clearly, the vast majority of surgeons prefer to place implants under the muscle but I would discuss the pros and cons of your particular circumstances with your surgeon.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

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I prefer to put breast implants under the muscle

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There is not one correct answer but i personally prefer to almost always put the implants below the muscle since they are less palpable, they look more natural, you get a better mammogram and there are less likely to develop hard capsules.

It is best to "err" on having your Breast Implants placed UNDER the muscle

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Because ALL breast implant RIPPLE and PLEAT, only a few people with a fair amount of breast tissue already available can adequately cover the implants and hide these imperfections. The BEST way to produce a great breast Augmentation result is to find an implant that fits a woman's chest wall AND is covered by her present breast tissue.

Since the vast majority of women seeking breast Augmentation do NOT have a lot of breast tissue cover, we prefer to place breast implants UNDER the Pectoralis Major muscle which lies under the breast gland. This way, the top 1/3 of the implant (the part most likely to show ripples when standing) is covered by the muscle and existing breast gland. As a result, the overwhelming majority of breast Augmentations in the US are done UNDER the muscle.

Peter A. Aldea, MD
Memphis Plastic Surgeon

Under vs. Over the muscle

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My preference is under the muscle.  This is more painful, but tends to give the best long term result with less chance of contracture, ripples, visibility, more protection, less chance of bottoming out.  Others may have other reasons for over.


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This is one of those "grey" areas of plastic surgery and different opinions are the norm.

However, given that 1 out of 7 females in this country develop breast cancer in their life time, I always place the implant under the muscle, since it allows better visualization of breast tissue during mammography.

Michael A. Jazayeri, MD
Santa Ana Plastic Surgeon

Breast Augmenation: Over or under the muscle

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If you want the most natural-looking breast, you will need a subpectoral implant, in which the implant is placed under the muscle. This procedure requires the merest incision—about three centimeters in the crease under the breast or at the edge of the nipple—and diminishes the incidence of capsular contracture, the formation of hard scar tissue around the implant, which occurs in 10 to 30% of cases.

Once the incision is made, the surgeon creates a pocket into which the implant is inserted, which in your case, would be located beneath the pectoral muscle underlying the breast tissue. Subpectoral implants aren’t right for everyone, though. If you have saggy breasts, an implant placed under the muscle won’t fill out that empty breast sack, and you’ll get what we call the “double bubble” look, where the breast hangs several inches below the implant.

Michelle Copeland, MD, DMD
New York Plastic Surgeon
4.6 out of 5 stars 10 reviews

Subglandular vs Submuscular vs Dual-Plane Breast Augmentation

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This is one of the debates that rages on in the plastic surgery community, with surgeons on both sides of the fence.  However, more and more surgeons prefer the partial submuscular, or dual-plane approach these days.  It really is a misnomer that the implant is completely under muscle.  In reality, only part of the implant is under the muscle ( usually the top 2/3 to 3/4), which is why some people prefer the term dual-plane.   Going on top of the muscle makes the recovery a little quicker, and allows the implant to settle faster, but if you are thin, then the chance of seeing the implant or feeling the implant are higher.  The rate of capsular contracture is also higher above the muscle.  When you go below the muscle, recovery is a little more painful the first few days, but not any longer in terms of length of time.  The muscle can help mask the implant to a degree, as well as keep the rates of contracture lower.  The muscle still works completely normal, but some women can flex their muscle over the implant, leading to a temporary shift of the breast under extreme muscle flexion.  It can look a little odd at first, but does get better with time.  There is a myth that on top of the muscle looks more fake, or more real, etc.  They are all myths - either way can look natural or more "fake", depending on the type and size of the implant used.  I hope this helps.

Under vs Over Muscle Implants

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There are benefits and disadvantages to both locations.  The benefits of under the muscle placement are a more natural feel and appearance as well as a smaller incidence of capsular contracture.  The primary disadvantage is more pain post-operatively.

John Whitt, MD (retired)
Louisville 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.