Can you have one implant under the muscle and the other implant above the muscle?

Doctor wants to leave one implant under the muscle and fix the other implant by going over the muscle that didn't heal from first surgery Will they look the same Please help

Doctor Answers 7

That plan doesn't make much sense to me

I think you need another opinion.  I assume that perhaps you are experiencing a contracture on one side?  The treatment for that is to place the implant under the muscle.  There are very rare cases where an implant should be placed on top of the muscle -- they just don't hold up as well.  Get another couple of opinions and make sure they are ASAPS or ASPS members.  Good luck.


Columbus Plastic Surgeon
5.0 out of 5 stars 15 reviews

Pocket Asymmetry

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:

  • 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:

  • 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.

In regards to your particular question, while it is possible to place implants in different pockets, this is not common. Placing one implant in the sub-muscular plane and the other in the sub-glandular plane will inevitably lead to a worsening asymmetry over time. However, without the benefit of an in-person exam, any advice offered will be of limited utility.  

As you can see 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.

Donovan Rosas, MD
Westchester Plastic Surgeon
5.0 out of 5 stars 7 reviews

One under one over?

It all depends. The muscle may blunt the visualization of the transition of the breast to the chest wall more so towards the breast bone than would a subglandular implant . Certainly with muscle movement there will be animation on the submuscular side and not on the subglandular side. While I have never had to resort to that plan, it certainly seems doable as long as you accept these minor discrepancies.  Good luck. 

Marc J. Salzman, MD, FACS
Louisville Plastic Surgeon
4.7 out of 5 stars 44 reviews

Can you have one implant under the muscle and the other implant above the muscle?

Thank you for your excellent question.  Placing implants in different pockets is strange  as they will cause your breasts to age differently.  I would recommend discussing this further with your surgeon to ensure that this is necessary.  

Nelson Castillo, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 43 reviews

Implant position

That sounds strange. It is unusual to place implants in different pockets. I feel in the long term you will have asymmetry.

Deborah Sillins, MD
Cincinnati Plastic Surgeon
5.0 out of 5 stars 10 reviews

Different placement

Hi 
that sounds very unusual
without knowing the particulars of your case eg pre op asymmetry, photos, complications, in general putting implsnts in different positions is not a good idea in the long term as it will invariably lead to asymetry

good luck!

Implant pocket position

It is a bit unusual to have one implant above and one below the muscle. They may look a bit different in the different pocket planes.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 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.