I'm a Runner and Lift Weights, Which is Better Subglandular or Submuscular? I Keep Seeing Mixed Answers.

I'm a Runner and Lift Weights, Which is Better Subglandular or Submuscular? I Keep Seeing Mixed Answers.

Doctor Answers 12

Regardless of activity levels, below the muscle is better for the vast majority of augmentation patients.

You are receiving mixed messages because although most surgeons agree that below the muscle is better in most patients, there will always be a few surgeons who will recommend above the muscle. It is important to ask WHY?

Before the FDA restrictions on the use of silicone gel implants (1991), the vast majority of implants used were silicone gel, and they were placed above the muscle. The operation was pretty easy, not too painful a recovery, and could be accomplished under local anesthesia plus sedation in many patients, allowing surgeons to avoid the hospital and increased costs. One downside of this common implant position was a significant capsular contracture (CC) rate. We now understand that this was likely from exposure of the implant surface to the bacteria that normally live in the breast ducts, and touch the implant when the breast is lifted off the underlying muscle. Bloody technique (blunt dissection) further compounded this problem, and CC rates ranged from 10% to as high as 40% or higher in some studies.

Textured implants were devised at this time to help to isolate bacteria and reduce biofilm-induced CC, as well as to "break up" the vector forces of collagen fibers aligned along the surface of a smooth implant. It worked--CC rates decreased. Antiseptic (Betadine) or targeted antibiotic irrigations (Adams formula) of the implant pocket further decreased the bacterial component of this source of CC. Careful technique became the norm for many scientific-minded and technically-adept plastic surgeons. Above the muscle was also thought to be better for women with some degree of ptosis (breast droop or sagging). CC rates dropped some, but were still a significant concern for above-the-muscle implant patients.

But in 1991-1992 the FDA restrictions meant that all plastic surgeons who were "used to" silicone above the muscle (smooth or textured) had to switch to saline-filled implants. Those of us in practice before 1991 who placed implants above the muscle naturally started simply using saline implants above the muscle . . . and started seeing new problems.

These included visible rippling, more edge appearance, and a less natural feel. Since most plastic surgeons were experienced in below the muscle placement of implants (such as for breast reconstruction after cancer mastectomies), we started placing our saline implants below the muscle. Less visible rippling, softer implant "edges," and a more natural look and feel resulted. But then we noted that some patients had activation distortion when the pectoralis muscles were contracted, and found a way to diminish this problem by dividing some of the inferomedial fibers of the muscle. Too much and there was a problem; too little and there was more activation distortion, particularly in women with some degree of sagging. But most of us who did lots of breast surgeries also noted a significant additional benefit--LESS capsular contracture! This gave further "proof" to the biofilm-induced CC hypothesis since below the muscle decreased the exposure to ductal bacteria, even if everything else was unchanged.

Of course there are some surgeons who just don't do a lot of breast augmentations, or adhere to their "old habits," or simply don't' want to "bother" with learning new or different surgical techniques once they are set in their ways. Some truly try to utilize a different technique for different patients, having seen some concerns with body builders with below-muscle implants.

I have performed breast augmentation both above and below the muscle for 27 years, and have placed implants in several Ms. Minnesota and Mrs. Minnesota bodybuilding champions, and countless other competitors, hobby bodybuilders, runners, and athletic types of women. I find that CC (which occurs more commonly with above the muscle placement) is much more disfiguring, as are the visible ripples, especially with thin athletic body types than the minimal concerns (activation distortion, double bubble) that rarely occur with below the muscle patients.

Sure, below the muscle has some concerns, duly noted, and yet has more advantages that outweigh these concerns for the majority of women in your situation. The key is selecting a skilled and experienced surgeon who can minimize the downsides, while taking advantage of the substantial upsides. Best wishes!

Minneapolis Plastic Surgeon
4.9 out of 5 stars 255 reviews

Breast implants for runners

Most often we find runners have very thin tissue coverage to hide an implant, and the submuscular approach will blend and hide the implant better, and the submuscular implant may remain softer over time. Weights may be an issue as the implant can push down and out with muscle pressure and you might have to work around this. Also, avoid a high profile implant as in a runner the look might be too round and projecting. If you are elite, we'll see you on the cover of Runner's World and avoid the implants altogether.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 42 reviews

For a weight lifter and runner is subglandular or submuschlar better?

You probably know the muscle behind your breast is the pectoralis muscle. You use it a lot in weight lifting and when swinging your arms while running. These activities do not cause abnormal movements of your normal breast. To best preserve your normal anatomy it's my opinion the best place to put your implant is in a potential space between your muscle and your breast, avoiding cutting into either one. Ideally your breast will cover and blend with your implant and it will be difficult if not impossible to see where one stops and the other begins. I think that will give you the most natural appearance and the least problems. If you chose to place the implant behind the muscle, each time you contract that muscle it will apply pressure to your implant and flatten it. This will be particularly noticeable with bench presses, push-ups, and all exercises that flex the pectoralis. My suggestion is subglandular placement of your implant and then work out as much as you like without worry about abnormal movement of your breast and implants. Good luck. 

Joseph Hayhurst, MD
Oklahoma City Plastic Surgeon

Submuscular Breast Implants in weight lifters/athletes

I have had many breast augmentation patients who lifted weights and were even body builders. They all have had submuscular breast implants without affecting their ability to lift weights afterwards. It is important to understand that the concept of submuscular placement really means part of the implant is under the muscle (upper part) and part of the implant (lower part) is under the breast tissue. This dual plane approach captures the benefits of both implant locations.

Barry L. Eppley, MD, DMD
Indianapolis Plastic Surgeon
4.7 out of 5 stars 72 reviews

Breast Implant Above or Below the muscle in a Runner

Hard to tell without an examination, but going under the musclel utilizing the Dual Plane technique will allow for the best of both worlds. The Dual plane techique releases the inferior edge of the pec muscle allowing it to sit partially under the breast and partially under the muscle. I believe the muscle is esential for long trem support of the implant. I would only place subglandular if you are a body builder and focus on developing very prominent pec muscles. Hope this helps.

Jonathan Weiler, MD
Baton Rouge Plastic Surgeon
4.9 out of 5 stars 85 reviews

Implant placement

It depends on the sizecand shape of your breasts and the amount of body fat that you have. If you have very developed pecs, going under the muscle can create a double bubble appearance. I think the correct answer is that A plastic surgeon who sees you in consultation will make a recommendation based on your specific needs and circumstances.

Robert L. Kraft, MD, FACS
New York Plastic Surgeon
5.0 out of 5 stars 40 reviews

Implant Placement and Athlete

Implant selection should be a collaboration between the patient based on her needs/objectives and the surgeon based on his or her expertise and experience. Each placement has its advantages and disadvantages. Consult with 3 board certified plastic surgeons to understand your options and choose the surgeon/surgical plan that best meets your needs/objectives.

Kris M. Reddy, MD, FACS
West Palm Beach Plastic Surgeon
4.4 out of 5 stars 41 reviews

Breast Implants

It is always great to stay in shape, and breast implants should enhance your life style without detracting from your exercise routine.  How much breast tissue you currently have would be a big factor in deciding between subglandular or submuscular.  Silicone does better in a subglandular position compared to saline because silicone has less wrinkles.  Many professional competitors for body building, in my experience, go under the muscle without problems or deformities.  The newly FDA cleared form stable cohesive gel implants are a recent new option to go subglandular.  There is no advantage to the new form stable implants if you go under the muscle.  The size you choose can also be a factor if you are a runner, since very large implants will add more weight and size to your upper torso.  It sounds like you could easily go under the muscle without impairing your exercise routine.  Then your chance of having a capsule will be lower, and you will have less chance of wrinkling.  So, good luck in your total program, and go over all the pros and cons with your surgeon before moving ahead.

Joe Gryskiewicz, MD, FACS
Minneapolis Plastic Surgeon
5.0 out of 5 stars 269 reviews

Athlete and breast implant pocket

In the majority of patients, I prefer breast implants to be placed under the muscle for numerous reasons.  It should not impact your strength.

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

Pocket position.

I used both approaches, however, 90% are subpectoral.  Activity is only an issue if you are a body builder.  I do not see a difference in recovery or post op activity whether above the muscle or subpectoral.

Steven S. Carp, MD
Akron Plastic Surgeon
4.6 out of 5 stars 32 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.