Should Breast Implants Be Placed Under or over the Muscle?

my friend went under the breast muscle w/ her implants...but now it looks rippling on the bottom. During consultation with a respected plastic surgeon in LA he told me under the pectoral muscle is much better... less risk from capsular contracture, safer for breast cancer screening, more natural (less stripper looking...his words, not mine!). Thoughts?

Doctor Answers 83

Breast Implants Under the Muscle

This may be a somewhat controversial statement, but in my opinion there currently is really only one acceptable position for breast implants in an elective cosmetic surgery patient: behind the pectoralis major muscle (sub-pectoral augmentation). There are a number of very compelling reasons to place implants behind the pec major, and the most compelling one of all is the fact that radiologists report that the mammographic imaging of breasts for the purpose of breast cancer screening tends to be more easily accomplished when breast implants are sub-pectoral (compared to pre-pectoral, also referred to as the 'sub-mammary' position). An American woman's current lifetime risk of breast cancer is approximately 1 in 8 to 1 in 9, so the issue of breast cancer screening must be taken very seriously. Mammography is by no means a perfect screening study, but it is the standard of care at this point in time. The most sensitive and specific test for breast cancer is a contrast-enhanced MRI scan, and breast implants do not impair breast tissue visualization by MRI.
The next very compelling reason to select sub-pectoral placement is a cosmetic one. Implants placed on top of the pec major tend to stand out in the upper pole of the breast, creating a rounded, convex and distinctly unnatural-appearing breast profile. With implants in a sub-pectoral position, the upper pole of the implant is flattened somewhat by the muscle, helping to create a smooth transition from the area in the upper chest where the breast begins, and a gradual slope towards the nipple that is not excessively rounded or convex. In some patients with a fuller breast volume preoperatively one may get an acceptable appearance with pre-pectoral placement - initially. The problem is that as breasts age, the fatty tissue atrophies and breast tissue thins out, and the area where this is most obvious is in the upper pole and cleavage area. So a pre-pectoral implant that was initially well-concealed may, after a few years, become painfully obvious (including visible implant folds and ripples) in the upper pole.
'Under the muscle' and 'sub-pectoral' are actually somewhat misleading terms, as in most cases the implant is only partially subpectoral. The anatomy of the pectoralis major muscle is such that it is actually just the upper/medial half of the implant that is covered by the muscle, while the lower/lateral half of the implant is submammary. The pectoralis major thus provides an additional layer of tissue to conceal the implant in the most cosmetically significant area of the breast: the cleavage area. This is why saline implants are often easy to feel laterally, as they are covered by breast tissue only in lateral aspect of the breast, and in slender patients who have small breasts preoperatively the implant is often immediately under the skin in this area.


Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 109 reviews

Over or under muscle placement of breast implants

One of the primary choices in breast augmentation is whether to have the implants placed "under" or "over" the muscle (submuscular or subglandular). This muscle is the pectoralis major muscle which lies over the rib cage and underneath the breast. It is the chest muscle that is commonly developed in weight lifters.

Traditionally, when the majority of implants were silicone, implants were most often placed underneath the breast gland and on top of the muscle. With the more common use of saline filled implants, it was noticed in women who were thinner or who had relatively little breast tissue to cover the implants, that there was a tendency to develop "rippling" or a waviness in the skin overlying the implant. This is especially true with the use of the "textured" or rough surfaced implants. In an effort to decrease the incidence of rippling and the potential for capsular contracture, there has been a move to place implants in the space beneath the pectoralis major muscle. Submuscular placement increases the padding overlying the implant offering more coverage and camouflage to the shape of the implant. Using this technique, rippling has become a rare problem

Today many more women have the option of silicone implants. The silicone implants are softer, re realistic in fell and the tissues tend to drape over them more realistically. They are also less prone to rippling. Consequently, it is possible to place them in a subglandular position more often while decreasing the risk of rippling. In fact a possible solution for rippling saline implants can be to replace them with silicone implants.

There are, however, some breast shapes that are better suited to a subglandular ("over" the muscle) placement of the implant. These women typically have breasts that at one time were much larger than the present. When there is a very large volume decrease and there is little or no shrinkage in the size of the skin envelope surrounding the breast tissue, then the shape approaches that of an "empty bag". Under these circumstances it is sometimes better to place the implant in a subglandular position in order to allow the implant to fill out the skin envelope of the breast.

Alexander G. Nein, MD, MS, FACS
Nashville Plastic Surgeon
4.3 out of 5 stars 23 reviews

Breast Implants Under or Over the Muscle-Which is Best

Opinions certainly vary but among most Plastic Surgeons today the most common answer you will get is under the muscle.

Benefits include:

  • ·         More tissue covering the Breast Implant
  • ·         Less risk of Visible folds or Ripples
  • ·         Less risk of firmness or capsular contracture

However Breast Implant under the Muscle can have disadvantages:

  • ·         More painful and longer recovery
  • ·         Visible muscle contraction around Implant during activity
  • ·         Interference with Pushups and weight lifting
  • ·         Higher position of Breast Implant which can cause unnatural look in sagging Breast
  • ·         Requires Breast Lift with extra scars if Breast is sagging

Breast Implants are still placed under the Breast in many people and can produce an equally nice natural looking result. Reasons for choosing under the Breast include:

  • ·         Easier Recovery
  • ·         A slightly sagging Breast when you do not want to have a lift
  • ·         Women with full Breast and adequate Breast Gland Tissue

It is wrong to be dogmatic and say there is only one way to place Breast Implants. You need to find an experienced Board Certified Plastic Surgeon and discuss your individual needs and preferences. See link below.

Under the Muscle is Usually Better for Breast Implants


Under the muscle is best for:

  • thin women
  • women with little breast tissue to cover the implant
  • women with little or no drooping of the breast
  • softer, more natural draping of the implant
  • concealing implant ripples
  • less chance of developing capsule contracture


Over the muscle is best for:

  • faster recovery
  • women with enough natural breast tissue to cover the implant
  • women with drooping who want larger breasts without a breast lift

 

These generalizations are meant as a guide: the best way to determine the optimal option for your particular anatomy and goals is in consultation with your plastic surgeon.

Paul C. Zwiebel, MD
Denver Plastic Surgeon
4.5 out of 5 stars 28 reviews

Why put breast implants either under or over the muscle?

I always say the same thing to my patients:  easier to get good mammograms, lower risk of capsular contracture, better camouflage of the upper edge of the implant by the muscle. So yes, all of the above, but don't forget that the implants are not covered by the muscle in the lower half of the breast. That's why you can still feel the rippling at the lower part of the breast if you have thin skin.  

And that is why a lot of women are choosing gel implants. Because even if you can still feel the implants, they feel softer and smoother when they are gel.  If you get saline implants I think it is important that they not be under-filled because they will feel more wrinkly.  I usually fill them up 10% over the minimum rated volume, e.g., a 300 gets filled to 330.  This helps.

Robert M. Lowen, MD
Mountain View Plastic Surgeon
5.0 out of 5 stars 41 reviews

Should Breast Implants Be Placed Under or over the Muscle?

Hello! Thank you for your question! Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts. Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years. In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance. Your breast width is the most important measurement.

Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant. This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape. Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width. Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later.

Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle). Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each. In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome. A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles. Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions. As you see, there are a few factors to decide upon for incision, placement, and implant type/size. Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits.

Hope that this helps! Best wishes for a wonderful result!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 21 reviews

Under the Muscle versus Over the Muscle Breast Implants

One of the great debates of breast augmentation surgery:  under the muscle or over?

Some surgeons only do 'over the muscle' and some only 'under the muscle'. 

What's the real scoop?  I guess that depends on who you ask. For most patients I prefer 'under the muscle' placement.  The muscle doesn't actually cover the entire breast implant, however.  The muscle covers the upper and inner parts of the implant.  The outer and lower parts of the implant are not covered by the muscle.  Technically this is called a 'partial subpectoral' or 'dual plane' technique.  Some surgeons actually use a completely 'under the muscle' technique, but most, like me, do not.  One main advantage of the partial subpectoral technique is that the muscle provides a little more padding, a little more thickness over the implant in the most visible areas of the breasts:  the parts of the breasts that are visible in bathing suits and low neck clothing.  Having that padding there minimizes the likelihood of seeing ripples/wrinkles in the breast implant in that location.  Under the muscle placement probably helps minimize the risk of capsular contracture, may make mammograms easier to interpret than over the muscle implants, and in my opinion the implants end up looking a little higher in the breast than over the muscle implants.  The biggest disadvantage of under the muscle implants is potential movement/distortion when the pectoral muscle contracts.  A woman who goes topless a lot, or a competitive body-builder who competes wearing fairly minimal tops may not like the distortion in shape that occurs when she contracts her pectoral muscles.

Over the muscle implants may work well in someone who already has a moderate amount of breast tissue and someone who has a little droopiness of her breasts.  In my experience over the muscle implants tend to settle a little lower on the chest.  This works if there is a little droopiness of the breasts and the woman does not necessarily want or need a lift.  However, with less padding between the implant and the skin than under the muscle implants, there is more potential for ripples/wrinkles to be visible exactly where you don't want that: the upper inner part of the breast.  You don't want to be in a bikini top at the pool leaning over to get your Coke and every wrinkle become visible. 

So, under the muscle versus over the muscle both have advantages and disadvantages. In my practice it's not a one-size-fits-all situation.  I use 'under the muscle' placement for most women, but some choose and do well with 'over the muscle'.  Visit with two or three surgeons and see what they say specifically in regard to you, your physical findings, and your desires.

Kelly R. Kunkel, MD
Fort Worth Plastic Surgeon
4.8 out of 5 stars 20 reviews

Mostly Below the Muscle, but Above Works Too.

I have put most implants below the muscle: 
-Less capsular contracture.  3 times less 
-Better implant coverage, Less wrinkling and palpability.  
- Perhaps easier to read mammograms
- Better upper pole contour. 

However, above the muscle:  
-Textured implants improve capsular contracture rate
-Shaped implants have less wrinkles. 
- Less chance of abnormal muscle motion. 

If you decide to go above the muscle, I suggest shaped, textured implants will work better.  

Above or below pectoralis muscle for breast implants - Submuscular implants

Breast augmentation should generally be made under the pectoralis muscle to decrease descent of the implant, capsular contracture, and palpability of the implant.  There are only a few cases that necessitate subglandular breast implant placement. 

Raffy Karamanoukian, MD, FACS
Los Angeles Plastic Surgeon
4.8 out of 5 stars 90 reviews

Breast implant question

 Implants can be placed under over the muscle for various reasons. My personal preference is to place them under the muscle for the reasons you mentioned, such as decreased capsular  contracture and better feel and look. However there are some reasons you may put the implant over the muscle.
Those who workout heavily such as bodybuilders  may prefer this approach. Or for  patients who have a lot of excess breast tissue or skin, placing the implants under the gland may look better. I would go through the pros and cons of each approach a note that surgeons have their own specific preference as well. 

Kailash Narasimhan, MD
Sherman Plastic Surgeon
5.0 out of 5 stars 12 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.