Breast implants under or over the muscle for nordic skier and trail runner? (Photos)

Dear megs79,

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, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Under muscle with dual plane can cause animation deformity and weaken the muscle, which is a bigger problem for athletic women. Better options are split muscle or over the muscle using the subfascial plane. This works well with Motiva implants.

Answer from Dr. Sean Hill, Board-Certified Plastic Surgeon at Lone Star Plastic Surgery – Frisco, TX:
Choosing the right implant placement plane is a key decision in achieving the most natural, long-lasting, and beautiful results — and it should always be based on your unique anatomy, lifestyle, and goals. There’s no one-size-fits-all approach.
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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.

In my experience, most patients tolerate under the muscle augmentation without issue or long term consequence. Based on your photos, it would be the preferred approach because of your lack of soft tissue coverage,

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 (ABPS) can help guide you in your decision making process.

Breast implants under the muscle. No problem skiing nor running. I have triple crown body builders, sky divers, kick boxers, and scuba divers with dual plane all back full speed 2 to 3 months post op with no problems. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

When there is any question about muscular performance it is always safer not to disrupt the muscle and place the implant sub glandular. However I agree that your skin is fairly thin and you run the risk of having visible rippling in the upper pole of the of the breast. This is less of a problem with modern implants but it's a risk that is completely eliminated with sub muscular or dual plane positioning. I believe it a dual plane is the superior technique for muscular placement. These are frequently procedures requested by young, healthy, active women and I have not experienced any coming back with complaints of diminished muscular capacity. So the choice is ultimately yours. You may have a small and likely imperceptible diminishment in your pectoral strength with dual plane placement while eliminating the risk of rippling versus sub glandular placement where your muscular function will not be disrupted anyway but the rippling risk slightly elevated. More cohesive implant that has a lower risk of rippling and sub glanular placement no may be a compromise that could work well for you. Take time to discuss your options with your surgeon and always consider second opinions.

Once you are fully healed from surgery you will be able to resume your active lifestyle with either implant placement. Having implants placed under the muscle would be beneficial for you since you don't have a lot of breast tissue. The muscle will provide some camouflage of the implant in the upper portion of the breast. Under the muscle placement also carries a lower incidence of capsular contracture. I've included a video that I hope you find helpful.