What are the pros and cons of under vs over the pectoral muscle for a first time breast augmentation procedure?

I'm wondering what the pros and cons are for placement of the implant? Take out breastfeeding as an issue. I've heard conflicting comments on placing the implant under the pectoral muscle (i.e. Longer recovery time, lifting free weights would be an issue) yet some doctors highly suggest under as its more natural looking, less likely to shift out of the pocket? I know it will really depend on my body and what not but any starting point would be helpful.

Doctor Answers 11

Over versus under?

Over or 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.


Louisville Plastic Surgeon
4.7 out of 5 stars 44 reviews

Dr Kayser

Thank you for your question. There are pros and cons to each location. The more common approach is to place the implant under the muscle. This is performed mostly to achieve more adequate coverage over the implant so that visible and palpable deformities are less apparent. This is particularly true in women who are thinner and have a smaller coverage of breast over their chest wall. However, this will often result in what is described as an animation deformity where contraction of the chest muscle can result in visible flattening and irregularities of the skin. The placement of the implant, however is never completely covered by muscle as the lower portion of the breast will still have only skin tissue which will still reveal some palpable or visible irregularities even when the implant is placed under the muscle. Another concern is that submuscular positioning can increase the gap between the breast and, for patients with minimal breast tissue, this can be a concern when cleavage is desired. Since every patient will naturally have scar tissue that forms around each implant, which is called a capsule, the advantage of placing the implant under the muscle is also thought to help decrease capsular contracture which is abnormal scar that develops around the implant.

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

Melek Kayser, MD
Detroit Plastic Surgeon
4.9 out of 5 stars 31 reviews

Breast Implants/ Breast Augmentation/ Anatomic Gummy Bear Implants/ Silicone Implants/ Breast Implant Revision Surgery

I appreciate your question.

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!

Dr. Schwartz
Board Certified Plastic Surgeon
Director-Beverly Hills Breast and Body Institute
#RealSelf100Surgeon

Implant Placement?

One of the most commonly debated choices is that of implant placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation:

  • 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:

  • 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.

Donovan Rosas, MD
Westchester Plastic Surgeon
5.0 out of 5 stars 7 reviews

Implant position

I think for most patients under the muscle is better becuase it provides more soft tissue coverage especially in the upper pole.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

What are the pros and cons of under vs over the pectoral muscle for a first time breast augmentation procedure?

If possible (breasts not sagging) a submuscular breast augmentation is preferred. Better coverage of implant, less visibiolty of implant edge, less risk of sagging, softer over the long term, better mammograms, possibly less risk of capsuolar contracture. Properly done there is no problem lifting weights and exercise. Downside is 3-4 more days of recovery and discomfort.

Breast Implants: Over or Under the muscle?

Thank you for your question!

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):
Potential Advantages:
  1. Pocket dissection is less traumatic compared to submuscular pocket
  2. This approach does not require dissection beneath the pectoral muscle
  3. The implant is not subjected to pressure or injury from muscle movement
  4. The implant can directly apply pressure on breast tissue to shape the breasts
  5. Direct pressure on breast tissue can correct constricted or tuberous breasts by stretch forces
  6. Direct pressure on breast tissue can correct some sagging/drooping of breast tissue
  7. The upper and inner breast areas can be more adequately filled
  8. Having the pectoral muscle underneath reduces the risk of implant displacement to the upper and outer side of the breast.
  9. Cleavage gap can be controlled more effectively.
Potential Trade-offs:
  1. Direct pressure on the breast tissue from large or high projecting implants may cause tissue thinning overtime
  2. Implant may interfere with breast imaging and mammography
  3. 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
  4. 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)
  5. There are higher reoperation rates
  6. 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
Please note that as a candidate for breast augmentation, subglandular implant placement may not even be recommended if you do not have more than 2 centimeters of soft-tissue in the upper pole of the breast.

Under the muscle (Partial submuscular): This pocket location best addresses the #1 priority in breast augmentation: maximizing long-term soft-tissue coverage.
Potential Advantages:
  1. 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.
  2. Having maintained the lower attachments of the pectoral muscle, the implant gets bottom support reducing the risk of implant malposition.
  3. With intact muscle attachments near the sternum, the risk of symmastia is reduced.
  4. Pocket provides less interference with mammography and breast imaging
  5. Pocket lowers the rate of capsular contracture
  6. Pocket provides breasts with a more natural upper pole
  7. Reduces reoperation risks for insufficient coverage
Potential Trade-offs:
  1. Dynamic pectoral muscle activity puts pressure on the implant distorting the breast shape and position in the long-term.
  2. 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.
  3. Muscle pressure at the lower regions may cause the implant to displace upward in small number of patients resulting in asymmetry.
  4. Muscle pressure can cause the implant to stretch out to the outer side of the breast, thereby widening the distance between breasts.
  5. Patients can experience more pain after surgery and require longer recover time compared to subfascial and subglandular pockets.
  6. Depending on the surgical technique and release of muscle attachments, you may experience less strength while flexing the muscle
  7. Pocket is not suitable for athletes and body builders
Hope this helps!

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 425 reviews

What are the pros and cons

Of course there are advantages and disadvantages of any approach. Implants placed under the muscle affords a thick layer of muscle to make the upper pole of the breast look much more natural, it creates a breast that stays softer than implants placed on top of the muscle and mammograms are much more accurate. The disadvantages are that the implants can move with muscular contraction of the pectoral muscles and the procedure itself is more tender for a week than implants on top of the muscle. Neither disadvantage is very significant for most people. In my practice we always prefer under the muscle for a first time augmentation.  Good luck. 

Robert Graper, MD
Charlotte Plastic Surgeon
4.5 out of 5 stars 26 reviews

Pros and cons of under vs over the pectoral muscle for a first time breast augmentation procedure?

Thank you for the question. There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”. The vast majority of breast implants placed in the "sub muscular" position are really being placed in the "dual plane" position ( partially sub muscular, partially sub glandular).

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

Hello and thank you for your question. I have many patients who are hardcore fitness enthusiasts and I have them back to their normal routine within a month even after breast augmentation under the muscle. If you are  lean, long-term, with larger implants, your tissue will thin and you may suffer from implant rippling, malposition, etc and most people do not have a lot of soft tissue support over the muscle and then down the line your fitness routine could be disturbed with the need for revision surgery; don't forget the downtime needed to have future surgery and also the costs of the procedure and also time off from work. In my opinion, going under the muscle has many benefits such as decreasing your chances for rippling, decreasing your chances for capsular contracture, increasing your chances for greater longevity, and also a more natural look. Dual Plane is where the muscle is separated from the gland inferiorly and allows the top of the implant to be more under the muscle where inferiorly towards your feet it mainly under the gland and there is no muscle. The benefits of dual plane are basically the same as subpectoral, but allow for better lower pole expansion and slight nipple elevation for cases of truly mild ptosis or slightly saggy breasts. There are many ways to perform plastic surgery and if you are not certain with the recommendations made by the surgeon whom you have seen, I think you should trust your intuition and I would encourage you to seek a second opinion via consultation with a board certified plastic surgeon with expertise in aesthetic breast surgery.


I hope this helps answer your question!

Sincerely,

Dr. Sean Kelishadi

Sean Kelishadi, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 22 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.