What's Better - over Muscle or Under Muscle Implants?

Should I get my implants over or under muscle? I am recieving conflicting opinions from plastic surgeons.

Doctor Answers 23

For flat breasts, breast implants work best under the muscle.

Hi.

1) We individualize based on the anatomy.  For relatively flat breasts with no excess skin (like yours), I think under the muscle is better (more of your own tissue covering the implants).

2)  When you are trying to correct some sagging with implants, then over the muscle generally better (implants fill skin envelope better if they are over the muscle).

3)  For body builders, always over the muscle.


Manhattan Plastic Surgeon
5.0 out of 5 stars 9 reviews

Breast implant placement

There are various factors regarding how you want your breasts to look and feel, but if you and your doctor have a good, open line of communication, you shouldn’t need to go back and forth on your decision. A major factor that effects how breast implants look and feel is whether they're inserted over or under the chest (pectoral) muscle. I do submammary and submuscular implants, inserting the implants under the breast tissue and over the muscle through an incision in the breast fold. The result is fabulous: perkiness with barely a trace of scar.

If you want the most natural-looking breast you'll need a subpectoral implant, in which the implant is placed under the muscle. This procedure also 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 percent of cases.

In short, you must know -- realistically -- what you are starting with, as well as what you want to look like when surgery is done. Do you want a natural appearance or a round, perky look? These are some of the factors I weigh with my patients when evaluating what type of procedure to do.

Michelle Copeland, MD, DMD
New York Plastic Surgeon
4.5 out of 5 stars 8 reviews

What's Better - over Muscle or Under Muscle Implants?

Hello! Thank you for your question! Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts. Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years. In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance. Your breast width is the most important measurement.

Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant. This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape. Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width. Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later. Very slightly less tissue may be visualized with subglandular implants, but not very significant.

Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle). Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each. In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome. A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles. Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions. As you see, there are a few factors to decide upon for incision, placement, and implant type/size. Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits.

Hope that this helps! Best wishes for a wonderful result!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 17 reviews

Under or over

SUB-MAMMARY POCKET (over the muscle)

The implant is placed over the chest muscle, under only the breast tissue.
- good for women with more of their own natural breast tissue so the implant can be hidden better. Also good for tuberous breasts.

SUB-PECTORAL POCKET - Dual Plane (under the muscle) - more common

The top part of the implant is placed under the chest muscle and the bottom third is covered by breast tissue.
-creates a natural teardrop shape. The implant is better covered so it's better for women with less of their own breast tissue. Makes mammograms easier to read.

Talk to the surgeon you feel most comfortable with about these options. 

Over Muscle or Under Muscle Implants

Each surgeon has his or her own preferences for the position of the implants based on experience and expertise. My general preference is under the muscle; however, the recommendation must be consistent with the patient's build and her needs/objectives. Choose the surgeon best understands your lifestyle, lifestage, needs and objectives, and has the demonstrated ability (through before and after photos) to provide you the look that you want.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon
4.5 out of 5 stars 32 reviews

Different opinions on this one

personally, i place almost all of my implants under the muscle.  this is usually done in a "dual plane" fashion, meaning, the upper 1/2 of the implant is covered by the pectoralis muscle, while the bottom of the implant is covered by the gland. 

the main motivation for this is to help to camouflage the upper pole of the implant.  a simple look at your picture shows that your ribs are quite visible.  you do not have much soft tissue in this area, and using the pec to help cover the implants will help to soften the edges of the implant, and therefore camouflage the implants.

some surgeons who are older than i am, practiced in the era of subglandular implant placement.  my feeling is that the trend has definitely moved to submuscular placement of the implants.  that is where i would place your implants if i were doing the surgery.

Eric Chang, MD
Baltimore Plastic Surgeon
5.0 out of 5 stars 10 reviews

Location of Breast Implants

Thank you for the question.

In my opinion,  there are numerous advantages of sub muscular (dual plane) breast augmentation. This  implant positioning will give you the best long-term aesthetic results and reduce the chances of complications such as significant rippling/comparability/ encapsulation and interference with mammography.

Best wishes.

Breast Implants - Above or Below the Muscle?

This may be a somewhat controversial statement, but in my opinion there currently is really only one acceptable position for breast implants in an elective cosmetic surgery patient: behind the pectoralis major muscle (sub-pectoral augmentation). There are a number of very compelling reasons to place implants behind the pec major, and the most compelling one of all is the fact that radiologists report that the mammographic imaging of breasts for the purpose of breast cancer screening tends to be more easily accomplished when breast implants are sub-pectoral (compared to pre-pectoral, also referred to as the 'sub-mammary' position). An American woman's current lifetime risk of breast cancer is approximately 1 in 8 to 1 in 9, so the issue of breast cancer screening must be taken very seriously. Mammography is by no means a perfect screening study, but it is the standard of care at this point in time. The most sensitive and specific test for breast cancer is a contrast-enhanced MRI scan, and breast implants do not impair breast tissue visualization by MRI.
The next very compelling reason to select sub-pectoral placement is a cosmetic one. Implants placed on top of the pec major tend to stand out in the upper pole of the breast, creating a rounded, convex and distinctly unnatural-appearing breast profile. With implants in a sub-pectoral position, the upper pole of the implant is flattened somewhat by the muscle, helping to create a smooth transition from the area in the upper chest where the breast begins, and a gradual slope towards the nipple that is not excessively rounded or convex. In some patients with a fuller breast volume preoperatively one may get an acceptable appearance with pre-pectoral placement - initially. The problem is that as breasts age, the fatty tissue atrophies and breast tissue thins out, and the area where this is most obvious is in the upper pole and cleavage area. So a pre-pectoral implant that was initially well-concealed may, after a few years, become painfully obvious (including visible implant folds and ripples) in the upper pole.
'Under the muscle' and 'sub-pectoral' are actually somewhat misleading terms, as in most cases the implant is only partially subpectoral. The anatomy of the pectoralis major muscle is such that it is actually just the upper/medial half of the implant that is covered by the muscle, while the lower/lateral half of the implant is submammary. The pectoralis major thus provides an additional layer of tissue to conceal the implant in the most cosmetically significant area of the breast: the cleavage area. This is why saline implants are often easy to feel laterally, as they are covered by breast tissue only in lateral aspect of the breast, and in slender patients who have small breasts preoperatively the implant is often immediately under the skin in this area.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
5.0 out of 5 stars 97 reviews

The Unders Have It

Dear Confused,

Although the choice of over versus under the muscle is there for almost everyone, certain body types lend themselves better to under the muscle.  Thin tissues on the chest wall such as yours is one of those body types.  Placement under the muscle would give you a thicker implant coverage a most likely a more natural result.  Also, placement under the muscle is less likely to result in tight capsular contractures, which can distort and displace implants.  Good luck!

Which is Better OVER or UNDER the Muscle Breast Implant Placement

All breast implants form ripples and folds (saline much worse than silicone filled). The most attractive breast augmentation results are obtained when the implant is covered completely by your tissues. Unfortunately, women present for breast augmentation precisely because they do not have sufficient breast tissues and want more volume. To cover the ripples of the implants, they are best placed under the pectoralis muscle under the breast in the majority of women.

Dr. Aldea

Peter A. Aldea, MD
Memphis Plastic Surgeon
5.0 out of 5 stars 93 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.