Implants for a weightlifter - over or under the muscle? (Photos)

Question

after having children I had a breast lift in 2022 after recovery. I got into the gym and have been doing a lot of weightlifting and CrossFit. I lost a lot of weight in my boobs went right along with it. The lift it self upheld well there is not loose skin, but there is zero upper pole. It’s FLAT. I have been doing my research and it is recommended to do over the muscle implants for people who are weight lifters is that true? As much as I want nice breast, I definitely want to get back into the gym after surgerysurgery. I am thinking 450 to 500 cc high profile silicone i, but have a fear of being top-heavy.

Paul E. Chasan, MD, FACS · Answer

Thank you for your question. I have been in practice for over 30 years and revisionary breast surgery is a large portion of my practice. When considering breast augmentation above or below the muscle, it is the lesser of two evils. Usually, the animation deformity from breast augmentation is minimal, however when you place implants on top of the muscle, the complications are significantly worse - slide down and wrinkling. I have a whole gallery of patient's with long-term changes with implants on top of the muscle. If you look at the fascia of the pectoralis major muscle, it is about the thickness of tissue paper. It is a fallacy that there is any strength in the fascia of the pectoralis major muscle. In reality, subfascial IS subglandular. You should be able to have an excellent result. Best wishes to you.

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation (“overs”):

•	Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster 
when compared to subpectoral augmentation.

•	Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).

•	Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.

•	Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.

Subpectoral Augmentation (“unders”):

•	Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.

•	Subpectoral implants have a lower rate of capsular contracture.

•	Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.

•	The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

The greatest effect of weight training in the setting of submuscular implants is animation. Muscle contraction over the underlying implant can cause movement of the implant and in some cases visible creasing (depending on the degree of soft tissue coverage). With regards to your specific question, there is a slight difference in strength post submuscular augmentation. This will not affect the vast majority of patients outside of the professional athletic set. As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other.  As always, your board certified plastic surgeon can help guide you in your decision making process.

Emre Guvercin, MD, FEBOPRAS · Answer

For someone who lifts heavy and does CrossFit, yes&mdash;over-the-muscle (OTM) placement is generally the better choice, especially since your prior lift has held well and your issue is upper-pole volume loss, not loose skin.Submuscular implants in athletes commonly cause animation deformity, chest distortion during presses and pull-ups, lingering discomfort, and a slower return to training. If getting back to the gym smoothly matters, avoiding the muscle is key.Size matters just as much as plane. While 450–500 cc high-profile implants can fill the top, they’re very likely to feel heavy and look top-heavy on an athletic frame&mdash;and can stress tissues over time. Many athletic patients later regret going that large.The most balanced, sport-friendly solution is OTM placement using a Preserve (tissue-preserving) technique with a Motiva Ergonomix 2 implant in the ~330–350 cc range. This restores upper-pole fullness without bulk, avoids animation entirely, feels lighter than traditional high-profile implants, and supports a faster, more comfortable return to lifting. Ergonomix 2 adapts naturally with movement, which suits an athletic lifestyle.Bottom line: For a weightlifter, OTM + Preserve + ~330–350 cc Ergonomix 2 is typically the most reliable way to get fullness without sacrificing performance or ending up top-heavy.

Darryl J. Blinski, MD · Answer

The one post a photo is not helpful because it’s in clothing so best of virtual con with and then we can determine the size and the range ranges. I would recommend placement of the implant in the DUAL plane so above the muscle, but under the fascia of the muscle and size wise to be determined also shaped to be determined, expect a possibility of use of an internal bra technique fee range, depending on type of implant style and use of internal bra mesh $8000-$15,000. Best of virtual consult with.

Implants for a weightlifter - over or under the muscle? (Photos)

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