Should I Go Over or Under the Muscle?

I am currently a 34 B. I breast-fed 2 children.I used to be a full C up before my kids. I am 36 years old, 5 "4" and have mild sagging,loss of volume to my breasts. My nipple is still above crease. I am in great shape except for my empty breasts. I want to be a D cup and am opting for 450cc gels, moderate profile. Cant decide on the placement.

Doctor Answers 31

Over or under the muscle?

I have to agree 100% with Dr. Stephenson. Your breasts demonstrate pseudoptosis, or bottoming out of the glandular tissue. The nipples, I think are OK, but really need the side view to knwo for sure. If you go with under the muscle, but do not use a dual plane 2 or 3 (probably a 3 in your case) technique, the glandular tissue will fall off the front of the impalnt like a "snoopy dog" deformity. The dual plane technique allows the impalnt to better fill out the lower pole of the breast.

You could also go above the muscle to fill out the lower breast, but you will pay a big price: You will have no muscle covering the implant which may make mammography more difficult, the implant will be more palpable and visible and feel and probably look less natural, especially as your tissue looks thin. Although there are those that will dispute me, I believe that there is no extra downtime for a submuscular dual plane technique than a subglandular (above the muscle) technique as I can easily obtain a 24 hour recovery with the former. In my opinion, there is no indication to use an above the muscle approach. I haven't placed an implant above the muscle in about ten years.


Stony Brook Plastic Surgeon
4.9 out of 5 stars 218 reviews

Kind of Both

A couple of observations.  It appears that you may have some mild breast ptosis and the upper portion of the breasts are empty.  I would recommend a dual plane placement.  This means the upper portion of the implant is beneath the muscle which gives you fullness but makes the edges of the implant less visible. The lower portion of the implant is covered by the breast tissue only.  This allows the nipple to move upward somewhat to help correct your ptosis without incisions for a lift.  Thanks for the picture.  

Dr. ES

Above or below the muscle

Your photo is very helpful in answering this question. You have lost breast volume which is most apparent in the upper pole of the breast. The breast has fallen because the skin has lost its' ability to retract. Volume replacement is needed to restore a youthful shape and position of the breast. More volume is needed in the upper pole than the lower pole.
Placing an implant below the muscle adds another layer of your tissue to the upper pole of the breast in addition to the implant. The muscle will also compress the upper part of the implant slightly making the border of the implant less apparent. This yields a more natural appearance to the breast. As you continue to age the volume of the upper pole of the breast  will continue to decrease, this is what makes implants under the breast more apparent over time.

In addition to this the incidence of visible rippling and capsular contracture are higher in the subglandular (under the breast) position. 

I hope this was helpful 

Robert W. Kessler, MD, FACS
Corona Del Mar Plastic Surgeon
4.9 out of 5 stars 119 reviews

Implant Size Suitable for Your Body and Frame

Factors which contribute to the outcome of Breast Augmentation are #size, #shape, and #profile. The #profile is determined by the amount of #projection versus roundness that the you desire, as well as the #size of the implant and size of your chest. Also, the placement or incision location will also have an effect on profile.

This may also provide some insight. If a woman wears a size 36 AB bra and would like to be a C cup, which is the average size that women wear and the average size bra that is sold, she needs a volume of approximately 350 to 390 cc to make that change. This becomes less if she's wearing a 34 bra, because it has a smaller strap size and the cups have a smaller diameter. A smaller diameter implant would then be a volume of approximately 300 to 350 cc. In the same way if she was more petite, maybe a double zero or size one and wore a 32 AB bra, then to become a 32C cup she would only require about 250 to 300 cc. The profile is determined by the amount of projection versus roundness that the you desire, as well as the size of the implant and size of your chest.

As much as it's important to know what size bra you currently wear, the strap size is important to know as well. It affects the diameter of the cup and subsequently the diameter of the #breast implant that you choose. In my practice, about 15-20% of the patients are good candidates for silicone #shapedimplants.
#Subpectoral or #submuscular implants refer to placement under the muscle which still remains the most common placement in the United States. #Submammary or #subglandular implants are the placement under the breast tissue in front of the muscle. This tends to more common in Europe and South America. General guidelines suggest that women with larger drooping (ptosis) breasts that do not want a breast lift often have the implant placed above the muscle, although another option, #DualPlane, has become more popular. In the Dual Plane method, the implant is placed under the pectoralis muscle but the breast tissue is also release, in part, from the muscle. Those patients with minimal breast tissue should usually have the implant placed beneath the pectoralis muscle for more soft tissue padding.
Your Plastic Surgeon will measure you to determine the best shape, size and placement of the #implants to be used. Lastly, another important element to a satisfying result of your #augmentation is realistic #expectations.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 90 reviews

Should I Go Over or Under the Muscle?

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 22 reviews

Sagging can be corrected without lift

You may not need a breast lift, however to determine this you would need a consultation with a surgeon who has experience with performing breast augmentation on breasts affected by mild to moderate sagging. You can consider Allergan Inspira Truform 2 implants with a narrower base width for more projection.   

Please see an experienced board certified plastic surgeon to find out whether you are a suitable candidate. Best of luck.

Breast Implants Over or Under the Muscle?


Should breast implants go over the muscle or under the muscle - which is better?
An implant placed above the muscle is referred to as 'sub-mammary' (or 'sub-glandular'), while an implant placed under the muscle is referred to as 'sub-pectoral' (or 'sub-muscular'). The muscle in question is the pectoralis major. The term 'sub-pectoral' or 'sub-muscular' is somewhat misleading, as implants placed under the pec major are only partiallycovered by the muscle. The pec major covers the upper/medial half of the breast area, so a 'sub-pectoral' implant is truly subpectoral only in the upper and medial aspect of the augmented breast, while the lower and lateral aspect of the implant is actually in a sub-mammary position. Because sub-pectoral implants are, in reality, both sub-pectoral (upper/medial breast) and sub-mammary (lower/lateral breast), this placement has more recently been referred to as a 'dual plane' approach to breast augmentation.
There is also 'total submuscular' implant placement, in which the implant is positioned behind the pec major and the serratus anterior muscle, so that the entire implant surface is covered by muscle tissue. This is not commonly done for cosmetic breast augmentations, but has been used for breast reconstruction using breast implants.
There are a number of compelling reasons for selecting subpectoral placement over submammary placement. The most significant is that fact that radiologists have indicated that it is easier to image breast tissue by means of mammography when the implant is subpectoral. The pec major also provides an additional layer of tissue to conceal breast implants in the 'social aspect' of the breasts - that part that is easily visible in swimsuits and lower-cut clothing. Additionally, the pec major is quite effective at flattening the upper pole of a breast implant so that a natural slope for the upper aspect of the breast is created.
Implants placed on top of the pec major tend to look very convex in the upper pole. The breast begins quite 'abruptly' in the upper aspect of the chest, and the appearance is therefore distinctly unnatural. Submammary implants are also more likely to have visible implant folds and ripples in the cleavage area. Another consideration is the fact that there is some evidence which suggests that the risk of capsular contracture may be lower with subpectoral implant placement. Even if the risk of contracture is the same, a mild contracture tends to be less noticeable and therefore less of a problem for the patient when the implants are in a subpectoral position.
Submammary placement may produce a reasonable result for fuller figured patients with larger starting breast volumes, as the larger amount of natural subcutaneous fat and breast tissue helps to conceal the implant contours. The problem is that as breasts age, they tend to deflate - especially in the upper pole. So what was adequate implant coverage in the cleavage area at age 27 may be inadequate coverage at age 37, and implant folds and ripples gradually become visible. So subpectoral placement is the best choice for both the short and long term.
'Sub-fascial' breast augmentation is also possible. Fascia is the term for a sheet of connective tissue made of collagen, and the pec major has a fascial covering as most muscles do. Breast implants can be placed behind the pec major fascia only, rather than behind the entire muscle, however this approach is not widely used. The pec major fascia is a relatively thin layer of tissue, so it is not nearly as effective in concealing breast implants as the actual muscle itself. Partial sub-fascial placement can be useful in some breast augmentation revision surgeries, where variations in pec major origin or incorrect release of the pec major has resulted in significant distortion of breast appearance when the muscle contracts.   

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 109 reviews

Dual Plane Breast Augmentation For Glandular Ptosis

Thank you for your question and photograph. An in person consultation is required for an accurate recommendation.

However I agree with the other doctors answering this question that you appear to have glandular ptosis which is breast gland below the inframammary crease but nipple areola above.

If this is the case then a biplanar sub-muscular breast augmentation should be possible without risking the "snoopy deformity".

Please consult plastic surgeons who are certified by the American Board of Plastic Surgery, experienced in cosmetic breast surgery and have an excellent reputation in your community. A careful and thorough consultation is required to help you make this important decision. You are fit and have normally shaped breasts and should be able to achieve an excellent result.

Over or under muscle (breast aug)

I would recommend under the muscle because more tissue will cover skin that looks a bit thin. You also may ptosis, which may require a lift, but it is hard to know without a side view.

Placement of implant

When I discuss about placement of the implants; on top vs behind the muscle, I tell my patient it depends on the amount of breast tissue you begin with.  If you have adequate amount of breast tissue for padding purposes, then you can have the implants placed on top of the muscle. If you do not, then placing the implant behind the muscle would be the better choice. In addition, I also look at other parameters, such as where is the upper breast border in reference to the nipple position as well as the inframmary crease. Remember, the implants have to sit above the inframmary crease. So, if your nipple sit high above the crease, then there is a possibility that you may still have some sagginess after the surgery, and that you may need a lift afterward. To answer your question about the implant placement, based on what I see, I feel you can have either one. You have to factor in all other parameters and the risks and complications of each placement to help guide you on your decision. I hope this helps. I am sorry, but there are a lot of parameters and factors that have to be taken into consideration.

Kim-Chi Vu, MD
Portland Plastic Surgeon
5.0 out of 5 stars 7 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.