Under Vs over the Muscle Placement for Silicone Breast Implants?

I am getting 400cc moderate plus Mentor Silicone gel implants on Monday! And I still have to choose over or under the muscle. I am 5' tall and weigh 101 lbs. I have only one child and do plan to have more. I am full 32A/B in cup size now. I just still don't know what to choose.

Doctor Answers 12

Breast implant sizing

Generally submuscular implants have many advantages. You should also be aware that there are many other factors that will determine the quality of your results.

Much of the final “look” achieved after breast augmentation surgery  depends on several factors:

1. The initial shape, size (volume of breast tissue), symmetry of the patient's breasts. In general, the better the  preoperative breast appearance the more likely the breast augmentation “look” will be optimal.

2. The experience/skill level of the surgeon is important in determining the final outcome. For example, the accurate and gentle dissection of the breast implant pockets are critical in producing  long-term  well-placed breast implants. I personally think that these 2 factors are more important than any others, including type (saline or silicone)  or model (low/moderate/high profile)  of implant.

3. The type of implant used may  determine the final outcome, especially if the patient does not have significant covering breast or adipose tissue. For example, some surgeons feel that silicone implants have a more natural look and feel than saline implants because silicone gel has a texture that is similar to breast tissue. Each patient differs in the amount of breast tissue that they have.  If a patient has enough breast tissue to cover the implant, the final result will be similar when comparing saline implants versus silicone gel implants.  If a patient has very low body fat and/or very little breast tissue, the silicone gel implants may provide a more "natural" result.
On the other hand, saline implants have some advantages over silicone implants. Silicone implant ruptures are harder to detect. When saline implants rupture, they deflate and the results are seen almost immediately. When silicone implants rupture, the breast often looks and feels the same because the silicone gel may leak into surrounding areas of the breast without a visible difference.  Patients may need an MRI to diagnose a silicone gel rupture.   Saline implants are also less expensive than the silicone gel implants.
Other differences involve how the breast implants are filled. Saline implants are filled after they’re implanted, so saline implants require a smaller incision than prefilled silicone breast implants.
On May 10, 2000, the FDA granted approval of saline-filled breast implants manufactured by Mentor Corporation and McGhan Medical. To date, all other manufacturers’ saline-filled breast implants are considered investigational.
As of 2006, the FDA has approved the use of silicone gel implants manufactured by the Mentor Corporation and Allergan (formerly McGhan) for breast augmentation surgery for patients over the age of 22.

4. The size and model of breast implant used may  make a  significant difference in the final outcome. Therefore, it is very important to communicate your size goals with your surgeon.  In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural” or “C cup” or "fake looking" or "top heavy" means different things to different people and therefore prove unhelpful.
Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also be inaccurate.
I use  intraoperative sizers and place the patient in the upright position to evaluate breast size. Use of these sizers also allow me to select the breast implant profile (low, moderate, moderate plus, high-profile) that would most likely achieve the patient's goals. The patient's goal pictures are hanging on the wall, and allow for direct comparison.
I have found that this system is very helpful in improving the chances of achieving the patient's goals as consistently as possible.
By the way, the most common regret after this operation, is “I wish I was bigger”.

I hope this helps.

San Diego Plastic Surgeon
5.0 out of 5 stars 1,487 reviews

Over or under the muscle for silicone breast implants requires careful decision

Your surgeon should be helpful in your decision whether to have silicone gel implants under the muscle-subpectoral or under the breast-subglandular.

Both methods of breast augmentation can provide pleasing results if done by a properly experienced board certified plastic surgeon.

Submuscular breast implantation is an easier, less complex surgical procedure with less post operative pain. The coverage of the implant by muscle provides additional coverage of the implant which helps hide the implant and any "rippling " that may occur.

However, contraction of the pectoralis muscle during exercise and many different motions can cause a visible movement and displacement of the implant.

Subglandular placement works very well in full breasted women with adequate breast tissue to cover the implant. There is a slightly increased risk of firmness of the implant (capsular contraction) long term with implants placed in the subglandular location.

Generally, mature women with slight sagging and adequate breast tissue choose subglandular in my practice.

Younger women with small breasts, minimal breast tissue and upright youthful looking breasts without sag choose the submuscular location.

View a picture of submuscular breast augmentation.

Under Vs over the Muscle Placement for Silicone Breast 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 26 reviews

Above or Below the Muscle Breast Implants

There are advantages and disadvantages to both that must be understood for an intelligent decision to be made. First of all, as by other doctors, present day opinion (without scientific validation) favors a submuscular placement when considering the interpretation of mammograms. It is debatable that this is a major consideration. The placement of your implant will be determined during consultation with your doctor or physician.

If a breast is tubular in shape or if it is modestly ptotic (droopy), there is a definite aesthetic advantage to placing the implant above the muscle. The ultimate shape is more natural when the implant is in this subglandular position.

As a rule, since saline implants are filled with water and not thicker silicone gel, they feel more natural when more tissue covers the implant. Women who have some breast volume to begin with can expect a more natural feel to the breast.

Consequently, saline implants are preferred deep to the pectoralis muscle all other variables being equal. More tissue covers the implant (the pectoralis muscle is another layer of tissue) making them feel somewhat more like normal breast tissue. A submuscular implant may be distorted when the pectorallis muscle is being used. During certain strenuous chest exercises such as swimming or weight training, the implant may be temporarily misshapened as the pectoralis muscle is exercised. This is very subtle and seldom a problem for our patients.

Submuscular placement does not involve cutting of any muscles and does not diminish muscular strength. Patients comment that post-operative pain is greater in the submuscular position. This generally equalizes with the subglandular placement in a few days, but is a consideration, nonetheless. After the appropriate convalescence, it is permissible to resume the normal range of activities.

Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon
4.7 out of 5 stars 35 reviews

Depends on your physical makeup and what you are trying to achieve

Implants placed under the muscle tend to sit higher on the chest and give more fullness above the bra line. Implants placed above the muscle are more natural looking and tend to sit lower. Putting a 400 CC implant in someone of your cup size, height, and weight will probably put you into the full C cup range. Silicone implants don't ripple as much as saline implants ,and are the implant of choice when going sub mammary (above the muscle). This is the more common placement for patients in Latin America and Europe, but many of my patients request submuscular placement.

The bottom line is that you should talk with your plastic surgeon and make your decision after discussing the pros and cons.

Joseph M. Perlman, MD
Houston Plastic Surgeon
4.3 out of 5 stars 20 reviews

Between you and your surgeon

Although there is no question what I would do for you, which is placing the implants partially under the muscle, your decision depends on the discussion between you and your plastic surgeon. I firmly believe that partially under the muscle yields a prettier upper breast look, especially in a thinner woman such as you. Look at your surgeon's before and after photos to see what you like. Best of luck.

Dr Edwards

Michael C. Edwards, MD, FACS
Las Vegas Plastic Surgeon
5.0 out of 5 stars 35 reviews

Silicone breast implant placement depends

Most surgeons prefer to place implants under the muscle for two reasons.

First of all, in someone who is thin (like you seem to be given your height and weight), the muscle can provide an additional thin layer of coverage over the implant.

Secondly, and most importantly, there is evidence that shows that there is a lower risk of capsular contracture when the implant is below the muscle.

Since I have not examined you, I can't know if you have any reasons why it should not be put under the muscle. Only your surgeon knows if there is some specific reason as to why you should not have it under the muscle.

If you are concerned and are confused as to where to have the implant inserted, I recommend you contact your surgeon and ask him/her for their recommendation.

John Diaz, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 34 reviews

I would almost always go under the muscle in a patient as thin as you.

In my practice, under or over the muscle depends on the patient and the breast tissue and appearance before implants. In your case, you sound quite thin and though silicone ripples less than saline, rippling in the upper pole can still be a problem, so I would usually go under the pectoralis muscle for more upper pole coverage of the implant.

W. Tracy Hankins, MD
Las Vegas Plastic Surgeon
4.9 out of 5 stars 293 reviews

What did your surgeon recommend?

The choice of under or over should have been made in consultation with your surgeon. It sounds like you are thin so coverage will be an issue, which would be a factor in favor of going under. There are other options such as subfascial that are considered for athletic women who are at risk for muscle flexion deformities but this is also a decision that shouldn't be left to the last minute.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 52 reviews

Several factors, but you cannot lose by going under the muscle

There are several factors which are important to consider when choosing pocket location. Above the muscle will give you a better projection but the implant could be visible if you do not have enough breast tissue coverage. Other issues to consider include family history of breast cancer and nursing. In case of doubt, you can always go under the muscle.

Hisham Seify, MD, PhD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 19 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.