Should I have breast implants under the muscle or above?

My breasts were two very different sizes: 36B & D. I'm 5 10 and fairly active. 6 years ago, at 16, and after my growth platelets closed, I had surgery on my B, attempting to match the other. Turns out, I had a tubular breast, and so he cut the extra muscle before putting the implant under my pec. My implant hurts during physical activity, and it's much higher than the other side. I find it difficult to do pushups, etc. When I get both sides reconstructed, should I get implants above the muscle?

Doctor Answers 6

Implants, some advices:

Thanks for the question
I prefer use the Cohesive Gel - Silicone Breast Implants with textured cover ("gummy bear implants"), under the muscle. They are quite safe and aesthetically best as they give a firmer consistency, better projection and natural appearance.
Kind regards
Dr. Emmanuel Mallol.-

Dominican Republic Plastic Surgeon
4.7 out of 5 stars 270 reviews

Smooth round HP saline sub muscular dual plane transaxillary endoscopic is the most sophisticated approach

There are many advantages to sub muscular dual plane placement and very many disadvantages to sub glandular placement. I would see no indication to do anything but sub muscular. This can be best accomplished with the armpit approach. The most sophisticated approach to breast augmentation is through the armpit with a surgical camera (transaxillary endoscopic). Using this modern approach the space can be crafted under direct vision, with virtually no bleeding and no postoperative bruising. Most importantly, the shape of the breast is meticulously created. The other, older methods of insertion are technologically less advanced. Both silicone and saline implants can be placed through the armpit by a surgeon with skill and experience using this approach. The incision in the crease is the oldest method of placing the implants and puts a scar directly on the breast.

Subglandular silicone implant placement is the historical approach to this surgery, and was widely used in the 1960's. The implant edges are more visible, the risk of rippling is higher, the implant is in contact with the non-sterile breast tissue so the risk of infection and capsular contracture is higher. The interface between the breast tissue and the muscle is blurred so the implant interferes with mammography more than sub muscular placement. The blood supply surrounding the implant is worse so the risk of capsular contracture is higher. The support for the implant is less so there is more long term shape abnormalities and sagging. The look of a sub glandular implant is much less appealing than a sub muscular implant. The placement of sub glandular implants makes any subsequent revision surgeries more complicated and less successful. There are no advantages to sub glandular implant placement.

Gary Lawton, MD, FACS
San Antonio Plastic Surgeon
4.9 out of 5 stars 136 reviews

Tubular breasts, breast augmentation, above or below muscle

This sounds like a challenging situation, but can be addressed.  Your question is a good one.  So much depends on your breast volume, shape and tissue.  Hard to address without photos and exam.  You certainly can place the implants above the muscle but may result in implant palpability and ripples as well as capsular contracture.  In your situation however, it may be the best choice.  Make sure you seek expert opinion from an experienced plastic surgeon qualified by ASPS and ASAPS and who is interested in breast surgery.
There are many approaches to your quandry and I feel sure you can have a very good outcome.
Wishing you the best.

Paul Watterson, MD
Charlotte Plastic Surgeon
5.0 out of 5 stars 42 reviews

Implant Placement

Implant placement all comes down to the amount of breast tissue a person has. That being said, someone who is generally pretty active and who works out a lot might wan to discuss a subglandular placement with their surgeon. Having the implant under the muscle on a person who is in the gym a lot would cause the implant to be squeezed everytime you did any type of chest execrsise.

Lawrence Bundrick, MD
Huntsville Plastic Surgeon
5.0 out of 5 stars 7 reviews

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.

Marc J. Salzman, MD, FACS
Louisville Plastic Surgeon
4.7 out of 5 stars 54 reviews

Should I have breast implants under the muscle or above?

Thank you for your question and I am sorry to hear of your implant issues.  Without photographs or an in-person examination it is difficult to offer definite recommendations. Your pain may be related to the location of placement of the implants but could also be indicative of other issues, such as the development of capsular contracture or implant malposition.  I would recommend voicing your concern to your plastic surgeon, or seeking a second opinion from another board certified plastic surgeon for the best treatment options.  

Nelson Castillo, MD
Atlanta Plastic Surgeon
4.9 out of 5 stars 68 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.