Implant Placement Over/Under Muscle When Active?

I work out 3x a week (1x dedicated to upper body) and do power yoga once a week. My concern is that going under the muscle will interfere with my workouts. I'm a 34B/32C and have been told I have enough breast tissue to cover implants above the muscle but I'm worried about capsular contracture. I also haven't had kids yet so I'm not sure how implant placement will affect that when I do (years away), and knowing I'll need another surgery after that time, what's easier?

Doctor Answers 11

You can enjoy an active lifestyle with both submuscular and subglandular implant placement.

A common question from active women is if there’s an implant placement that’s better-suited to their activities. The truth is that you should be able to resume your full workout regimen once you’ve healed from breast augmentation, regardless of implant placement. The upshot with subglandular placement is that it involves a faster recovery, but as you’ve noted there’s also a higher chance for capsular contracture. Submuscular placement offers a more natural result, and for women who plan to breastfeed in the future, this placement does not interfere with the milk ducts and glands. A consultation with a board-certified plastic surgeon can help you explore your options further.


Eugene Plastic Surgeon
4.7 out of 5 stars 16 reviews

Breast Implant Placement Over/Under Muscle When Active?

There are so many benefits of placing the breast implant beneath the chest muscle including better coverage of the implant, less risk of capsular contracture, less risk of nerve injury to nipple, and others.  I have many active bodybuilder patients who have implants under the muscle and do just fine.

The key is proper placement of the implant with detachment  of the muscle from the fifth rib and not leaving too many fibers near the sternum or on the side which can cause animation deformity.  When you do vigorous pectoralis contraction such as bench pressing the muscle will tend to push the implant down but assuming you are not going to have very large implants over 350-400 cc in my opinion you should be fine.  Placing the implant under the breast on top of the muscle is a much easier and quicker operation which puts less work on your surgeon.  However long-term results in my experience are much better when the implant is placed under the muscle.


Implant Placement Over/Under Muscle When Active?

Greetings 

Thank you for your question There are various implant types and different techniques to place the implant. The proper implant size and shape will be chosen by your surgeon according to your desires. In suitable patients placing the implant from axillary area can be done however in some cases it is better to place the implant via T cut.

Bulent Cihantimur, MD
Turkey Plastic Surgeon
5.0 out of 5 stars 78 reviews

Dr Kayser

Thank you for your question. Based on your description, you would be an excellent candidate for an implant to be placed over the muscle. Traditionally, implants are placed under the muscle in order to provide better coverage in the upper and inner portions of the breast. This also is thought to help decrease capsular contracture, which is abnormal scar development that naturally forms around the implant. A submuscular implant will also result in a wider space between the breasts and most importantly, what is referred to as animation deformity, which is your primary concern.

The alternative placement of the implant above the muscle negates any interference of the muscle and its potential visible irregularities that do occur when contraction of the muscle occurs. However, this also can lead to more visible palpable and visible irregularities due to less coverage, especially in women who are lean and fit. The gap between the breasts however can be improved as migration of the implant towards the middle of the chest can be achieved. The risk of capsular contracture, however, is potentially higher in patients who have an implant placed above the muscle and, therefore, it is recommended that textured devices be used. Textured implants can also potentially help decrease the abnormal scar development as well. One other consideration is that implants placed below the muscle may actually improve mammogram visualization versus those with implants above.

In patients who are lean who desire an implant placed above the muscle, and ideal solution is to also provide fat transfer to supplement additional coverage. This would thicken the soft tissue envelope around the implant and also provide padding to areas that can often be irregular such as the bony sternum.

I would invite you to observe my video of an athletic patient who actually owns a gym who had her implants relocated from under the muscle to above the muscle with the combination of fat grafting that resulted in an excellent result. In any case, I would recommend that you seek out a consultation with a board certified plastic surgeon who is experienced in all types of breast surgery. I hope this helps and have a wonderful day. Dr. Kayser - Detroit

Melek Kayser, MD
Detroit Plastic Surgeon
4.9 out of 5 stars 31 reviews

Implants over/under muscle

Gels over the muscle tend to look more natural and recovery is easier. Higher filled Sientra gels or Natrelle Inspiras are a good option. Usually, intense body builders, etc use this approach to avoid implant muscle issues. There may be a slightly higher risk for capsule.

Most women benefit from implants under the muscle. Normal exercise usually does not pose any problems.

Either approach may require future surgeries.

An exam and consultation with a plastic surgeon is recommended to discuss your options and expectations. 

Implant Placement Over/Under Muscle When Active?

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.

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

Subglandualr vs. submuscular placement in the active patient?

If you have spent some time here reviewing patient questions and expert responses, you are probably very aware of how common this question is among prospective candidates. You appear to have a healthy understanding of the issues already.

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: sub-glandular/ sub-mammary vs. sub-pectoral/ sub-muscular? It is important to understand that there is no one absolute correct answer which holds true in every scenario. 

 

Subglandular Augmentation/Under the Gland/Over the Muscle:

 ·      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.

 

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

 

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

Implant pocket position

I have treated many, many women who are very active, and if have not had complaints about not being able to workout when the implants are under the muscle. If you want them over the muscle, that is a possibility as well. The majority that I place are below the muscle.

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

Under or Over in Breast Augmentation

You laid out the pros and cons very nicely.  If you have strong skin and are not so worried about getting droopy it sounds like over the muscle might be fine for you.  There is a little increase in the capsular contracture rate but it is not huge.  If you are more worried about being droopy after kids (Do women in your fasmily get really full bust line with pregnancy? Do they for example go from an A cup to a double D and then shrink again?) then consider under the muscle.

Regardless, you will at some time likely need a re-operation at some time because devices like implants eventually fail and your body will change with age and hormone changes no matter if you are over or under so that needs to not be too strong a consideration.

Great question and the best of luck for a wonderful result!

Deborah Ekstrom, MD
Worcester Plastic Surgeon
4.7 out of 5 stars 38 reviews

Under or over?

Breast implants can be placed either behind the breast tissue (subglandular), or behind both breast tissue and muscle (submuscular, subpectoral, dual plane). Because the pectoralis major ends at the level of the nipple, most submuscular implants are actually only partially covered by muscle, and the lower half to two-thirds of the implant is actually subglandular.

The lower incidence of rippling with today’s cohesive gel implants has allowed successful subglandular placement in many women, as long as you have some paddng over the implant. The advantages of subglandular placement include less pain postoperatively, and avoidance of “animation,“ where the breast implants move in an unnatural way when you flex your chest muscles.  If you are very thin or have minimal padding in the chest area, you may choose to place your implants partially under the muscle instead. This may give you a more natural upper slope of the breast, due to the additional padding of the muscle, but wider cleavage and implant movement with muscle contraction can be downsides.


I hope that helps-

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.