Over the Muscle - the Best Choice?

I had a consult with a local PS and he was very persistent that over the muscle would be the best choice for me. I am fairly active and lifts weights regularly. I am 5"5 and 162 lbs. I am currently a small 34 C. My concerns are sagging over time and having nice cleavage with the most natural feel/look possible. I only want to go up to a small D. I am also interested in silicone.

Doctor Answers 27

VIDEO: No right or wrong answer: Make a list, weigh the advantages/disadvantages and then choose: Over versus under the muscle

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Under the muscle is most popular but it has disadvantages: I am attaching a video of the animation deformity that occurs.

There is a very crude rule that essentially states that if you can pinch less than an inch of tissue from the upper portion of the breast than you should strongly consider going under the muscle.

Another aesthetic measure is that if you can see your ribs along the upper portion of your chest, then again, you should consider under the muscle. Why? Well if you don't have enough tissue to hide your ribs, you will not likely have enough tissue to hide your implant (which lies above your ribs).

Generally, if you go under the muscle, you should avoid pectoralis contraction/strengthening exercises to avoid pushing the implants to the outside of your chest. These tradiionally consist of avoiding the bench press, ped deck, butterflies, wide stance push ups. Generally these tend to not be popular with women anyway. You can usually perform all other exercises as long as they do not involve contraction of the pectoralis which will be obvious when it causes movement of the implants

Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

Putting breast implants above or below the muscle

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Going below the muscle hides the implant better, going above the muscle allows the implant to descent more naturally into your breasts.

Because of the shape of your breasts, I feel that going under the muscle would not be ideal unless you have a small breast lift at the same time.  Going under the muscle will keep the implant up high and thus you need to lift your natural breasts or you'll develop a 'double bubble' look where the implant is one bubble and the natural breast is hanging off it (the other bubble).  

For someone very active, you need to realize that every time you flex your muscles the implants will move.  While that may be a cool party trick, you may find it very annoying after some time.

The downside of going above the muscle is that yes, over time things will stretch and the implant will slowly move down.  Is this such a bad thing... I am not sure what the right answer is.  It comes down to your personal preference.

There are always pros and cons to every choice you make, neither one of these is superior to the other so that I would always insist that my patients go with one over the other.


Martin Jugenburg, MD

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 518 reviews

Implant positioning above and below the pectoralis muscle

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This issue is a bit like, which is better: saline-filled or silicone gel-filled implants. The difference is that above or below the muscle positioning of breast implants requires surgical technique and using past experience to decide which approach, properly done, will get the "best" result. 

Properly done today with dual-plane muscle release technique, subpectoral (below the muscle) positioning of implants is only in part of the upper half of the breast. The lower part of the breast has no muscle over the implant. This minimizes animation of the lower breast in women who use the pectoralis muscle actively.

The advantage of getting the implant below the muscle for the upper half is to pad, protect, and blend in the implant both short term and more importantly, long term. This gives a more natural look and minimizes the risk of noticeability of the implant in the upper breast. In my opinion, the other reasons to put the implant below the muscle such as reducing capsule contracture haven't held up. There is a small advantage to separating the breast tissue from the implant using the muscle for tests like mammograms. 

Most of the supposed reasons for putting the implant above or below the muscle are either wrong, haven't been supported by experience, or are inconsistent. Also, there is really no difference in the lower half of the breast where things like bottoming or sagging are supposed to occur because of the size, weight, or positioning of the implant. 

There are several errors made in the above answers regarding your situation based on the picture. Your breasts are not far apart at the base width. They are not saggy and require a lift (mastopexy). There is no problem getting implants placed correctly below (or above) the muscle in the lower half of the breasts. Your breasts are actually fairly typical of many women considering augmentation. They are pseudoptotic and not truly sagging. The lower half of the breast below the nipple-areola has to be filled out more than the upper half and an implant will do this if it's properly positioned and sized. This makes it look as if the breast was lifted but it's an illusion. It also requires lowering the inframammary crease level and lengthening the distance from the nipple to the inframammary crease. This requires experience but can be done quite reliably. 

I would recommend a partial subpectoral low profile saline or gel implant properly sized to the width of your breast and avoid the lift suggestion. This will give you the best short term and long term result and will increase you one cup size and make it look like your breast was lifted even though it wasn't. 

Scott L. Replogle, MD
Boulder Plastic Surgeon

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Over the muscle

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This is a good question. The fact that you are active, makes animation deformity from muscle contraction a potential issue for you as well as the fact that I believe submuscular implant placement can lead to implant malposition over time due to stretching of the capsule surrounding the implant.

When the chest muscle contracts it pulls the implant up and out- decreasing your cleavage- I don't think this is a natural look at all!

Based on what you describe- I would recommend silicone gel implants placed above the chest muscle. Saline implants would not be a good choice for you, as the irregularites of the implant would show through.

Sam M. Sukkar, MD
Houston Plastic Surgeon
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Over vs under breast implants for athletic women: other options

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Your question poses a classic and difficult dilemma for many women who are athletic. Implants are most often placed under the muscle for a more natural appearance and to provide better coverage, but using the traditional method they are subject to what are called "animation deformities" with muscle flexion. On the other hand, low body fat means coverage is needed all the more. There are 2 options that are worth considering that are designed to find a balance between these competing factors. One is called subfascial, which is above the muscle but under the muscle fascia. This provides some support but not "padding." The other is called a split muscle technique, which avoids the animation problems because it doesn't cut the muscle as in the usual technique but provides coverage for the upper part of the breast where it is most needed.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 59 reviews

Implants over or under or over the muscle?

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About 90% of the breast implants I do are under the muscle.  In your case, however, I would consider over the muscle.  You have plenty of breast tissue to provide padding over the implant (assuming you go with gels).  You are a weight lifter and implants under the muscle may bother you in the way they look and feel when you lift.  You also have ptosis (sagging) and putting the implants under the muscle may result in a "double bubble" where the implants ride high and the breast tissue sags over the lower end of them.  This looks bad. 

If the implants stay soft, getting a decent mammogram should be possible.  Also, other imaging techniques such as MRI are very sensitive in patients with implants, regardless of the location of the implants. 

If there were a really compelling reason to go under the muscle on you, I would also raise your nipples so they stay centered on the breast mound. 

Lisa Lynn Sowder, M.D.

Lisa Lynn Sowder, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 77 reviews

Breast implants for weightlifters

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Generally there is always a preference to having implants under the muscle because it will reduce capsular contracture, offer better viewing for mammograms and MRI's of the breast shape,as well as to protect the implants from injury.  Exceptions are made when the patient may be highly muscular and may see implant displacement with muscle flexion.  I am not sure that you are in this category without examinig you.  I would also suggest that you will need some type of lift to reduce the size of the areolae, as well as to elevate the breast shape.  Without this consideration the areolae will widen greatly with breast augmentation alone with your breast shape.  Good luck.

Breast implant position

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Thank you for the question and picture.
I think you would be best served with sub muscular breast augmentation.  This  implant positioning will give you the best long-term aesthetic results and reduce the chances of complications such as significant rippling/palpability/ encapsulation and interference with mammography.
Best wishes.

Breast Implants Under Muscle

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It is difficult to give you an answer based on your posted picture. My opinion is that under the pectoralis muscle is the best location for breast implants. I believe this for several reasons. First and foremost, radiologist tell me that sub pectoral implants interfere less with their ability to interpret mammograms that implants placed over the muscle. That is enough of a reason form me. Additionally, as my colleagues have written to you, placing the implants under the muscle provides more soft tissue coverage for the implant which is quite important. Thirdly, the implants is better supported and will maintain its position better over time.

Bernard A. Shuster, MD, FACS
Hollywood Plastic Surgeon

Under vs. Over the muscle

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There are some advantages of going over the muscle, but in most cases I prefer under the muscle. First of all it offers more camouflage for the implants so rippling is less evident, especially with saline implants. Secondly, going under the muscle has less interference with the milk ducts should you want to breast feed in the future. Discuss with your plastic surgeon your desired results and get his opinion. It is always a good idea to ask to see pictures and bring some of your own so you can better articulate your desires.

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.