Possible to Have over the Muscle Breast Augmentation After Mastectomy?

I am post bilateral mastectomy, after 10 years, I finally have expanders. They were placed in Nov. I am having pain 6/10 on one breast area and to the shoulder and arm.. I am afraid that after the implants I will continue having pain. Can the Breast implants be put over the muscle? Or is there an artificial muscle that can be used?

My concern is how to distinguish breast pain vs cardiac pain in the future. Implant schedule is in April.

Doctor Answers 14

Breast Reconstruction with Implants OVER the muscle after Under the Muscle Expansion

As a 10 year survivor, it is safe to say the breast cancer is behind you. However, to get good looking reconstructed breasts you must carefully navigate the limitations dictated by your mastectomies and remaining tissue characteristics.

The reason why the vast majority of implants in Breast Augmentation are placed UNDER the muscle is because all implants ripple and their shells are palpable. To get an attractive result, implants MUST be covered with as much tissue buffer as possible. Good results with breast implants placed under the breast gland / over the muscle can only be achieved in women who already have enough tissue to allow this coverage.

In Breast reconstruction, the breast gland and underlying muscle cover (the fascia) are removed with a varying amount of the breast skin. The left over breast skin is often thinner than normal breast skin. Any implant placed under these breast skin flaps over the muscle will be visible and palpable because BY DEFINITION these "breasts" had to have their soft tissue inner fill removed thereby denying implants the cover they need.

In Breast Reconstruction, placing the implants under the muscle is routine for the above reasons and you may choose to have silicone filled implants which are lighter, feel more natural and ripple less than the saline filled implants.

Dr. P. Aldea

Memphis Plastic Surgeon
4.9 out of 5 stars 108 reviews

Breast and Chest pain with under the muscle tissue expander reconstruction following mastectomy

It is quite common to have pain during the expansion process. This seems to be particularly worse about 4-6 hours after each expansion rather than immediately with injection. Typically surgeons may over expand and then place a final implant that is smaller than your fully expanded size which should provide you with some relief. The rate of complications and unacceptable appearance wtih over the muscle placement ( exposure, extrusion, capsular contracture, visible rippling, etc) generally preclude placing implants in that location following mastectomy.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 81 reviews

Breast pain during reconstruction should be evaluated, but may not improve on top of your muscle

Hi there-

Only your surgeon will have the understanding of what has occurred to date necessary to explain what might be causing your pain, and what options you have for improving it.

I would not, however, assume that your pain is due to the expanders being under the muscle, or that putting your implants on top of the muscle will make this better.

Talk to your surgeon about your situation and see what the two of you can come up with.

Armando Soto, MD, FACS
Orlando Plastic Surgeon
4.8 out of 5 stars 157 reviews

Implants after mastectomy

If you have had tissue expanders placed, you most definitely had them placed under the muscle and possibly even with Alloderm along the lower border. This is done so that there is adequate soft tissue protection over the implant when the permanent implant is placed.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Your discomfort should be better after switching to breast implants

It is pretty common to be uncomfortable while the expansion process is ongoing. When you change to implants they are much softer and move with the body better than the expanders. I agree that putting the final implants above the muscle is probably not a good idea unless you have very thick skin flaps. You need to have adequate coverage over the implants or they can be felt and in some cases extrude. Discuss your concerns with your plastic surgeon, they should be able to allay your concerns. Good luck, Dr T

Scott Tucker, MD
Winston Salem Plastic Surgeon
5.0 out of 5 stars 30 reviews

Implant placement after mastectomy

In most cases, it is best to have the implants below the muscle after mastectomy. During the mastectomy, all of the breast tissue was removed, which leaves only skin. It is not safe to only have a very think skin layer between the outside environment and the implant. If your expanders are in place under your muscle and you are still undergoing expansion prior to the final implants, you may have some discomfort during the expansion process. It is best to discuss this situation with your breast and plastic surgeons. If there is a lack of muscle then sometime a dermal substitute can be used to bridge the gap. Also, if you have muscle spasm, you may want to discuss Botox injection into the muscles to help them relax. Good luck with your recovery.

David Shafer, MD
New York Plastic Surgeon
4.9 out of 5 stars 75 reviews

Implants always under the muscle after mastectomy

Sorry to hear about your ordeal with the expanders. To clarify some terminology, implants after mastectomy is reconstruction, implants to make breasts larger is augmentation. When the breast tissue is removed, there isn't much of a layer left to cover and support the implants; that is why they have to go under the muscle. The tricky part is that the pectoral muscle only covers the upper 2/3, so if your expanders were placed usung a total muscle cover technique then additional muscles were raised (called the serratus anterior and the rectus muscle.) Your pain is likely related to that. Fortunately there is another option using a material called Alloderm, which can replace those muscles for implant coverage. I would ask about that option. 

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

Breast reconstruction and implant placement


Thank you for your question.

Expander pain and cardiac pain are very different. However, every patient is different and therefore experience different symptoms. It should not be assumed that the pain is from your expander, althought it is very common to experience this pain while your tissue is expanding. I would definitely seek medical attention just to be safe. Heart issues are often undiagnosed in women. Providing that the pain is from your expanders, the pain does subside in most patients once the implants are in.

Since you had a mastectomy, all of your breast tissue has been removed leaving basically just skin to cover the implant. The implants should be placed under the muscle to give more cushioning to the implants and provide the best results. There are products out there help with breast reconstruction such as Alloderm. It will provide more support. You should discuss all of your options and concerns with your surgeon.

Best regards,

Dr. Speron

Sam Speron, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 1 review

Possible to have over the muscle Breast Augmentation after mastectomy.

It is possible but not advisable. I would need to see photos and than can give a more specific response. Go see 3 boarded plastic surgeons in your area.


Darryl J. Blinski, MD
Miami Plastic Surgeon
4.6 out of 5 stars 173 reviews

Your breast pain can be because of capsular contracture

You should not have pain after reconstruction unless there is capsular contracture. Please get a consultation with your plastic surgeon. Post mastecomy, all implants are placed under the muscle to provide protection and coverage to the implants.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.8 out of 5 stars 122 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.