Would over or under the muscle be best for me and my asymmetry? (photos)

So far I have had two consultations with conflicting recommendations of over and under the muscle. One surgeon said that because of the direction of one of my breasts, it would be better to go over the muscle to prevent the breast being pushed more to the side over time. The other surgeon did not seem concern and advised under the muscle would be best. I am currently a B cup. Thoughts and recommendations on this are appreciated.

Doctor Answers 14

Dual Plane

From the look of your pictures I can only tell you what I would do. I do agree that the sub glandular approach will make the implants possibly closer together. However, with areolas  that already point outward, moving the implant too far inward will make this look worse. I would prefer using a shaped implant that's wider than it is tall, such as an oval base Sientra silicone gel implant. I prefer the dual plane in that it has better coverage in the cleavage area hiding possible wrinkles and certainly has less capsular contracture. There's no incorrect answer here just differences of opinion and differences in techniques. Best of luck.


Louisville Plastic Surgeon
4.7 out of 5 stars 44 reviews

Over or under

It sounds like the surgeon recommending over the muscle has a good plan.  Implants under the muscle will be pushed to the side over time and lateralization occurs.  Choosing to go over the muscle will remove that possibility and also provide more breast shape and can create tighter cleavage if desired as well.  It's less discomfort and easier recovery.  In my practice I would likely recommend the same.  Under the muscle could be a good option also as they have the benefit of having examined you in person.  Consider the options and best wishes!

Levi J. Young, MD
Overland Park Plastic Surgeon
5.0 out of 5 stars 44 reviews

Breast augmentation

Hello and thank you for your question. You are a great candidate for a breast augmentation.  Under the muscle with a dual plane technique has several advantages:  lower risk for capsular contracture, less risk of rippling, and more natural look and feel.   The size of the implant is based on your desired breast size/shape, your chest wall measurements, and soft tissue quality.  This decision should be based on a detailed discussion with equal input from both you and your surgeon.  This entire surgery can be performed with a small incision technique.  Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.  

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Richard G. Reish, MD
New York Plastic Surgeon
5.0 out of 5 stars 80 reviews

Breast augmentation over or under the muscle?

Thank you for your question.  When I look at your photos, I am not struck by any significant amount of asymmetry in your breasts.  Nearly every woman has one breast that is slightly different than the other in terms of size, shape, droopiness, or direction.

The majority of implants are placed under the muscle.  You will see the doctors mention "dual plane."  This is when around 3/4 of the implant is under the muscle and 1/4 (the lower 1/4 of the implant) is under just the breast tissue.  When you see or hear "under the muscle" or "subpectoral," think "dual plane" because for most surgeons, these terms are interchangeable, myself included.

I would recommend implants placed under the muscle.  The look is more natural because there is more of your own tissue covering the implants.  There is less rippling of the implants.  There is also a lower complication rate with implants under the muscle (such as capsular contracture).   Best wishes!

Sub muscular breast augmentation

In most cases sub muscular breast augmentation (breast implants under the muscle) is the better method.  In your case this is what I would suggest.  Your asymmetry is slight and can be corrected by using different size implants and strategic placement of the implants. Be sure to choose a board certified plastic surgeon with a great reputation and who specializes in breast augmentation.

Under vs Over Muscle

When done correctly, the placement under or over muscle will not effect the appearance of the breasts at all.  The best option is usually the dual-plane approach, where 3/4 of the implant is under muscle while the bottom 1/4 is under breast tissue.  This gives you the benefit of both - muscle coverage but soft and normal appearing.  When most surgeons mention submuscular, this is really what they are referring to.  I hope this helps.

Would over or under the muscle be best for me and my asymmetry?

You appear to have a normal, mild amount of asymmetry. A breast augmentation will increase your volume and projection, but not change that asymmetry. I think that there are several advantages if implants are placed behind the muscle. These include a decreased risk of forming a capsule, a decreased risk of implant visibility and a better mammogram in the future. Good luck!

Would over or under the muscle be best for me and my asymmetry?

Thank you for the question and pictures. It is extremely common to receive different opinions from different plastic surgeons about the best way to treat a specific “problem”. Each plastic surgeon may have his/her opinion that is based on their specific/unique education, experience, and personal preferences. Their opinions may also be shaped by unfavorable results they have encountered in their practices. It is quite amazing how adamant each plastic surgeon can be about the superiority of his/her recommendations…




Although these different opinions can be confusing and a source of anxiety for patients, it is good for patients to understand the different options available. Ultimately, it will be up to each patient to do their due diligence and select their plastic surgeon carefully. Part of this selection process will involve the patients becoming comfortable with the plastic surgeon's experience level and abilities to achieve their goals as safely and complication free as possible.


There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”.    I will try to outline some of the differences here;  you may find the attached link helpful as well.



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 these sub muscular position.    You may find the attached link helpful to you as you learn more. You will find a separate page, on the same website, dedicated to breast asymmetry concerns. Best wishes with your decision-making outcome and for an outcome that you will be very pleased with.


Subfacial plan for desired result

Thanks for submitting your photos. Based on them my advice to you would be a subfacial plan. You will achieve a good shape and a long term result. Please consult with a board certified plastic surgeon. Kind regards and good luck.....


Ozge Ergun, MD
Turkey Plastic Surgeon
5.0 out of 5 stars 13 reviews

Would over or under the muscle be best for me and my asymmetry?

There are so many advantages to submuscular placement of the breast implant this position using a dual plane approach is almost always my first choice.  Proper placement in technique using the dual plane procedure should not adversely affect your nipple or breast position. Find an experienced board certified plastic surgeon.

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.