Why is under muscle placement more commonly recommended than over muscle?

Question

Why do many plastic surgeons recommend more under the muscle placements, rather than over the muscle, when there are a lot more problems with under the muscle placement (especially lateral displacement & animation deformity compared to capsular contracture with over the muscle placement)? That doesn't include the other problems that come under the muscle such as capsular contracture, bottoming out and double bubble.

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation (“overs”):

•	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 (“unders”):

•	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.

•	The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

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.

Carlos Marciales, MD · Answer

Thank you for your for asking, subpectoral placement has lower risk of visible rippling especially in individuals with thin breast tissue, and subglandular placement looks more natural, and it behave like a normal breast tissue with time, Ultimately, the choice between subpectoral and subglandular placement should be made based on individual patient factors, including breast anatomy, tissue characteristics, and aesthetic goals. Ensure to discuss these options thoroughly with a qualified plastic surgeon to determine the most suitable approach for achieving the desired outcome.

James Lee, MD · Answer

Thank you for your questions! Subpectoral (under muscle) placement and subglandular (under muscle) placement refer to the placement of breast implants either partially beneath the chest muscle or directly behind the breast tissue. However, subpectoral placement is generally more commonly recommended due to its potential for a more natural look, reduced risk of capsular contracture, and lower risk of visible rippling especially in individuals with thin breast tissue. Ultimately, the choice between subpectoral and subglandular placement should be made based on individual patient factors, including breast anatomy, tissue characteristics, and aesthetic goals. Ensure to discuss these options thoroughly with a qualified plastic surgeon to determine the most suitable approach for achieving the desired outcome.

Daniel Barrett, MD · Answer

Dear Punkratty,
I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

George Volpe, MD · Answer

There are pros and cons of submuscular versus over the muscle breast implant positioning. The pros for over the muscle include decreased pain and no dynamic flexion motion. This means if one is actively flexing their pectoralis muscles, the breast does not move. Although most patients with under the muscle implant do not exhibit this, it is sometimes seen. There is also less swelling in the early healing time with over the muscle implants. Under the muscle implants (sub muscular) also has benefits. This includes ease of getting mammograms for monitoring for breast cancer in the future, a lower risk of capsular contracture (opposite of what the person who posed the question stated) less chance of feeling the implant and possibly less sag in the long run. I must state in our practice the vast majority of our implant placements are under the muscle. I find it is rare that a woman will be concerned with motion of the breast when lifting. We do discuss activities and proper resumption of training especially for the bodybuilding women in the practice.

Reza Rod, MD · Answer

Most surgeons believe that it looks and feels more natural to place the implants under the muscle. Capsular contracture is actually reduced by nearly 18% to less than 10% in primary aug patients when placed under the muscle. It is best to consult a board certified Plastic Surgeon for a consultation.

Paul E. Chasan, MD, FACS · Answer

Thank you for your question.  A large portion of my practice is dedicated to breast revision surgery. I have been in practice for 28 years, so I have some perspective. I have a whole gallery on my website dedicated to long-term changes associated with implants on top of the muscle. It is very rare for me to see someone who has had subglandular breast implants have an excellent result after 5 to 8 years. The vast majority of them slide down the chest and/or have capsular contracture. Breast augmentation is not a perfect operation, but is a very good operation. When you put all the potential problems associated with breast implants, the curve definitely favors placing them under the muscle. Best wishes to you.

Ted Eisenberg, DO, FACOS, FAACS · Answer

I recommend an in person consultation with a plastic surgeon to discuss your goals and be measured. After I measure and discuss goals with my patients, we then look at pictures of women (my patients) with similar measurements with different size and style breast implants, if interested. They also get to see what they would look like when the breasts have fully dropped and fluffed and in clothes. You get to see actual results and the surgeon's experience and not a virtual idea of what can be achieved. Women tell me that this process is very helpful in determining what size and style breast implant is right for them. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Connie Hiers, MD, FACS · Answer

Long term, placement behind the muscle give better upper breast fullness that looks natural, more support to the implants with less sagging, and avoids seeing the edge of the implants in the upper breast. It is more painful initially as the muscle has to relax. Also, there is some muscle flexing when exercising. There is a lower risk of capsule formation as well and more protection to the implant. Bottoming out is more related with choosing an implant that is too large and it is placed on top of the muscle. The double bubble is more related to lowering your natural breast fold. For women with no or little breast tissue, under the muscle is the best choice long term.

Camille Cash, MD · Answer

When deciding on where to place the implants it is important to know the pros and cons.  Placing the implants under the muscle carries a lower risk of capsular contracture, supports the implant, and provides coverage for the upper portion of the implants.  This placement also gives a more natural appearance to the breast which is good for those wanting to avoid a "fake look".  When implants are placed subglandularly the skin envelope is the only support for the implant so they may sag more quickly, especially larger implants.

Why is under muscle placement more commonly recommended than over muscle?

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