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 79

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
5.0 out of 5 stars 88 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
Nashville Plastic Surgeon
4.5 out of 5 stars 19 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 20 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 37 reviews

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
5.0 out of 5 stars 74 reviews

Breast Implants, under vs over the muscle

Under the muscle placement is actually a misnomer, since the upper portion of the implant is placed under the pectoralis muscle, but the lower portion resides beneath a woman’s lower breast tissue.  It therefore should be more accurately labeled “partial submuscular placement”.  Implant location is based on how much soft tissue- muscle, fat and existing breast tissue- a woman has.  In general, small breasted women and most with moderate sized breasts would benefit from camouflaging their implants from showing rippling through the skin by placing them under the muscle to afford more padding over the implant surface.  Those women who have naturally large breasts and want to be larger with implants (rarely seen by me) could have the implants placed over or under the muscle to get a similar result. 

Steven Yarinsky, MD
Albany Plastic Surgeon
4.5 out of 5 stars 8 reviews

This is why I prefer to place breast implants below the muscle...

For most of my patients, placing breast implants below the pectoralis muscle is preferable. Implants placed below the muscle will have the following benefits:

1) Reduced risk of capsular contracture

2) Reduced risk of infection

3) Reduced risk of implant exposure

4) More natural appearance; especially on the upper portion of the breast.

It is important to realized that implants placed below the muscle, are mostly below the muscle...not completely below the muscle. In almost all women, there is no definable pectoralis muscle underlying the lower outer portion of the breast. Therefore, the ability to feel and see the implant below your breast skin in this location always exists.

Kevin Brenner, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 20 reviews

Breast Implant Placement - Over vs Under the Muscle

Best practices are to place the implant under the muscle, although there are rare cases where it is better to place the implant over the muscle. The reason why it is better to place the implant fully under the muscle or partially under the muscle is because it creates a more natural look and feel, reduces the risk of capsular contracture and allows for significantly more visibility during a mammogram.

With saline implants, rippling can occur whether the implant is placed over or under the muscle. This is due to the structure of the round implant and the amount of tissue covering the implant. This occurs more commonly in patients who have undergone breast augmentation over the muscle, but is also seen in thin patients. Silicone implants are often a better choice if you are concerned with rippling. They also have a more natural feel because they more closely resemble the texture of natural breast tissue.

Under or over (the muscle): Which is better?

There are a few indications when breast implants are better suited to subglandular (on top of the muscle) placement: a) Women who have adequate breast tissue; b) women who have "constricted" or tubular breasts and do not want a breast lift; c) women who are professional body builders, where the lateralizing action of the pectoralis major muscle may prove to be a distraction.

Apart from these circumstances, most PS recommend the dual plane (below the muscle) location because it appears to provide certain advantages: a) prevents overly rapid downward displacement; b) more resistant to capsular contracture; c) provides a mroe attractive superior pole with additional tissue to camouflage possible wrinkling and rippling; d) better visualization of breast tissue on mammograms. This last reason, alone should convince women that the short term additional discomfort is worthwhile.

When the gummy bear gel implants are reintroduced, the subfascial (essentially subglandular) plane may be popularized again. Good luck.

Lavinia K. Chong, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 54 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.