What are the pros and cons of under vs over the pectoral muscle for a first time breast augmentation procedure?
Doctor Answers 11
Over versus under?
Both the subglandular (on top of muscle) and submuscular (under muscle) approaches to breast augmentation are used today by plastic surgeons. There are advantages and disadvantages to each of these approaches. For the use of a sub glandular implant, most plastic surgeons would consider how much glandular breast tissue will lay above the breast implant to allow it to be more hidden. In thinner patients, with sub glandular implants, especially saline, visible wrinkling can be a problem. There are just a few advantages to the sub glandular placement. For the first few days or so, it is certainly less painful to put in a sub glandular than a sub muscular breast implant. The sub glandular placed implant will look more properly in position earlier without the overlying tension of the pectoralis muscle allowing the implant to ride higher in the chest for a few weeks. Also, in the case of a patient with a wide breastbone and the wish for a more narrow cleavage, the placement above the muscle will allow for more movement of the implant towards the center of the chest thus narrowing the space between the breasts. In patients with thin overlying breast tissue, especially with larger implants, the outline of the implant is more visible through the tissues with the implant placed above the muscle. We do know that the rate of capsular contraction is higher in implants placed above the muscle than implants placed below. The sub muscular approach has a few advantages. One important one is that mammography is a little easier to do and to read when the implant is placed below the muscle. There is also less wrinkling, less visibility, and less rate of capsular contracture. Other than being more painful for a few days after surgery, another issue with the sub muscular placement is animation. When the pectoralis muscle is activated, it will push the breast implant upward as well as outward which can be visible through the skin. Another consideration in this choice of whether the implant is sub glandular or sub muscular is that in today's modern breast implant surgeries, most of the time, a dual plane approach is utilized. In this way, the upper part of the breast implant is placed below the muscle and the lower part can be placed either on top of the muscle or below the lining of the muscle called fascia. With this approach, the bottom of the implant in the sub muscular placement can be in the same place and position as if the implant was placed on top of the muscle. This is the technique used by most plastic surgeons today. Each surgeon has their own preference and I would recommend that you seek out the consultation with a board-certified plastic surgeon and asks them what their choices for you would be and why. Good luck with your surgery.
Placement of an implant above the muscle will yield less coverage which could increase visible or palpable irregularities particularly in thin patients. The implant however can be placed closer together and so this may help to improve women who have a large gap between the breast. Because the implant no longer involves the creation of a muscle pocket, no animation deformity would be present. However, there are concerns that abnormal scar formation or a capsular contracture can be higher in women who have an implant placed above the muscle but the risk may be lowered if a textured implant is selected rather than a smooth one. Be aware that there is an extremely rare possibility that a type of cancer, called acute large cell lymphoma, has been found in patients with textured implants, however, its treatment is essentially complete with removal of the implant and scar tissue envelope.
One final option would be the ability of placing the implant above the muscle but supplementing it with fat transfer. This would likely be a great choice in a thinner patient who desires to have an implant placed above the muscle which would necessarily eliminate the animation deformity but allow greater coverage by placing that as well. Fat is natural and yours and has the potential to last a lifetime but it too has potential risks. In any case, I would recommend a consultation with a board certified plastic surgeon who is experienced in all forms of breast surgery. I hope this helps and have a wonderful day. Dr. Kayser - Detroit
Breast Implants/ Breast Augmentation/ Anatomic Gummy Bear Implants/ Silicone Implants/ Breast Implant Revision Surgery
The best way to determine implant size is based on chest wall measurements that fit your body. Once we determine that we can choose the profile based on what you want or need to achieve.
Implants under the muscle, there is less risk of capsular contracture. Anatomic implants tend to give a more natural shape with more nipple projection.
The best way to assess and give true advice would be an in-person exam. Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.
Best of luck!
Board Certified Plastic Surgeon
Director-Beverly Hills Breast and Body Institute
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- Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster when compared to subpectoral augmentation.
- Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).
- Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.
- Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.
- Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.
- Subpectoral implants have a lower rate of capsular contracture.
- Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.
Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other. As always, your board certified plastic surgeon can help guide you in your decision making process.
What are the pros and cons of under vs over the pectoral muscle for a first time breast augmentation procedure?
Breast Implants: Over or Under the muscle?
It is great you are doing research, and the fact that you are finding conflicting information is exactly why you must consult with a board-certified plastic surgeon to make informed decisions based on evidence.
Nevertheless, below I list out the pros and cons for under and over the pectoral muscle.
Over the muscle (subglandular):
- Pocket dissection is less traumatic compared to submuscular pocket
- This approach does not require dissection beneath the pectoral muscle
- The implant is not subjected to pressure or injury from muscle movement
- The implant can directly apply pressure on breast tissue to shape the breasts
- Direct pressure on breast tissue can correct constricted or tuberous breasts by stretch forces
- Direct pressure on breast tissue can correct some sagging/drooping of breast tissue
- The upper and inner breast areas can be more adequately filled
- Having the pectoral muscle underneath reduces the risk of implant displacement to the upper and outer side of the breast.
- Cleavage gap can be controlled more effectively.
- Direct pressure on the breast tissue from large or high projecting implants may cause tissue thinning overtime
- Implant may interfere with breast imaging and mammography
- There is often insufficient soft tissue coverage in the upper and inner sides of the breast and often fails to provide a natural superior pole
- Implant is exposed to endogenous bacteria in the breast tissue, resulting in higher rates of capsular contracture (the main reason why today most surgeons place their implants under the muscle)
- There are higher reoperation rates
- There is greater risk of symmastia (i.e., disappearance of cleavage) when cleavage gap is reduced too much and it can be difficult to correct
Under the muscle (Partial submuscular): This pocket location best addresses the #1 priority in breast augmentation: maximizing long-term soft-tissue coverage.
- With additional soft-tissue coverage, the risk of uncorrectable implant edge visibility and rippling in the upper and inner sides of the breasts is reduced.
- Having maintained the lower attachments of the pectoral muscle, the implant gets bottom support reducing the risk of implant malposition.
- With intact muscle attachments near the sternum, the risk of symmastia is reduced.
- Pocket provides less interference with mammography and breast imaging
- Pocket lowers the rate of capsular contracture
- Pocket provides breasts with a more natural upper pole
- Reduces reoperation risks for insufficient coverage
- Dynamic pectoral muscle activity puts pressure on the implant distorting the breast shape and position in the long-term.
- Muscle pressure may not allow the implant to fully rest at the lower portion of the pocket leaving a triangular dead space that fills with fluid and is replaced by fibrous tissue.
- Muscle pressure at the lower regions may cause the implant to displace upward in small number of patients resulting in asymmetry.
- Muscle pressure can cause the implant to stretch out to the outer side of the breast, thereby widening the distance between breasts.
- Patients can experience more pain after surgery and require longer recover time compared to subfascial and subglandular pockets.
- Depending on the surgical technique and release of muscle attachments, you may experience less strength while flexing the muscle
- Pocket is not suitable for athletes and body builders
What are the pros and cons
Pros and cons of under vs over the pectoral muscle for a first time breast augmentation procedure?
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 the sub muscular position.
I hope this, and the attached link, helps. Best wishes.
Going under the muscle is usually better
I hope this helps answer your question!
Dr. Sean Kelishadi