Over muscle vs under muscle? I am looking for a natural look, concerned my chest muscles will distort my breasts

I have triple crown body builders who start working out for their next competition by 6 to 8 weeks. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Without seeing your pictures, for athletic patients with strong pecs who want to avoid animation deformity, subfascial placement is a great option. This is above the muscle but below the tough fascial layer of the muscle, so the muscle stays down on your chest wall in its anatomic position. This gives a more natural look and has a lower risk of capsular contracture than subglandular placement (the old style of "above the muscle"), based on the studies we have. If you're very lean, you may benefit from fat grafting as well to soften the edges of the implant further.

Thank you for your question.
I have many patients who are very athletic whether they are consistently working out or participating in cross-fit programs who will get breast augmentations. My recommendation is to place the implants above the muscle. With a below the muscle breast augmentation, there is a risk of the implant moving laterally, towards the axilla area which is not a great aesthetic. With an above the muscle breast augmentation, it will look natural. Given the choice, I would recommend silicone over saline implants for a more natural appearance.

Historically, only professional bodybuilders had their implants placed over the muscle even though they are perhaps the worst candidates due to low body fat and atrophic breasts from male hormones. Outside that group, it is more variable. However, one should not discount the fact that implants placed over the muscle have a higher risk of capsular contracture and implant palpability and visibility compared to under the pectoralis. Here in LA, so many patients who are very active in their respective sports have their implants placed under the muscle and are very happy with their appearance. What's crucial to both animation deformity and muscular function is choosing the appropriate implant dimension for that individual; oversized implants can lead to stretch deformity, malposition, and then animation deformity.

Dear vdowney77,
I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Thank you for sharing your question. In most cases breast augmentation patients benefit from a below the muscle placement as it offers more natural results and trends towards fewer long-term complications.

With little breast tissue, implants always look better under the muscle and long term have much less sag. However, there will be muscle flexion with implants behind the muscle.

Thank you for your question. I would suggest having the implant placed in the sub facial pocket with a moderate to moderate plus profile implant. The sub facial pocket will avoid implant animation (movement of the implant with contraction of the pectoralis muscle). A moderate or moderate plus profile will help to smooth the transition from the chest wall to the implant and give you a more nature look. Consult a board certified plastic surgeon to help you determine the optimal size implant for your body type.

Hi, vdowney77 ! Thank you for your question.
In patients will little breast tissue, and if there is not a significant skin drop, we usually place the implant under the muscle, so the volume of the muscle also helps and looks more natural.
However, in patients who have breast ptosis (sagging) we might need to place the implant over the muscle, to get a better lifting effect.
To understand which plane fits better for you, it is better for us to evaluate with your photographs.

Thank you for your question, and it is a very good one. It's hard to comment specifically on your case with out pictures, but in general, if you have very strong pectoralis muscles and are athletic, going under the muscle can look less natural than going over the muscle. Even in patients with a small amount of breast tissue going over the muscle with a silicone gel implant may be the best option. Please see a board certified plastic surgeon experienced in breast augmentation utilizing implants both above and below the muscle. Good luck!