Implants under or over the muscle?

Placement Of Implant For Petite Or Thin PatientsSub-muscular is still the most common placement, especially with low body fat. I am not sure why you would consider different placement.

There are pros and cons to the placement of breast implants and
the “sub muscular” position versus the "sub glandular position”.
I will try to outline some of the differences here; you may find
the attached link helpful as well.

I think it is in the best interests of most patients
seeking breast augmentation surgery to have implants placed in the “dual plane”
or sub muscular position. This positioning allows for more complete
coverage of the breast implants leading to generally more natural
feel/look of the implants in the long-term. This position will also
decrease the potential for rippling and/or palpability of the implants
(which may increase with time, weight loss, and/or post-pregnancy changes).
The submuscular positioning also tends to interfere with mammography less
so than breast implants in the sub glandular position. The incidence of breast
implant encapsulation (capsular contraction) is also decreased with
implants placed in the sub muscular position.
On the other hand, sub glandular breast implant positioning does not have
the potential downside of “animation deformity” ( movement/ distortion of the
breast implants seen with flexion of the pectoralis major muscle)
they can be seen with breast implants placed in these sub muscular
position. Also, the immediate recovery period may be more
comfortable after sub glandular breast augmentation as compared to sub
muscular breast augmentation surgery.

The goal of breast surgery is to achieve beautiful
breasts. Beauty is determined by several factors including symmetry, skin
tone, position of breast on the chest wall, position of areola, cleavage and volume. 

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. Both saline and silicone gel implants can produce a good cosmetic result in the appropriate patient. Most patients prefer the feel of the silicone gel implant.

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