What is the Difference Between over the Muscle and Under the Muscle Breast Implants?

Implant placement relative to the pectoralis major muscle
continues to be a source of controversy.Although the majority of plastic surgeons prefer submuscular placement,
there is still a large group of plastic surgeons who feel strongly about
subglandular placement.Each group can
make convincing arguments regarding their position of choice.It’s safe to say both approaches have
advantages and disadvantages.In the
context of these discussions, we feel that every patient needs to be considered
individually.Each patient has unique
anatomic findings that affect the decision to place the implant under or over
the muscle.The aesthetic goals of the
patient are equally important and have a significant impact on the decision as
well.The vast majority of patients are
striving for larger breasts with a natural look.They want balance, harmony and proportion
with the surrounding structures.The
majority of breast implants are placed in a submuscular position.There are several advantages to this
approach.These include more soft tissue
coverage which results in fewer visible folds, creases and ripples in the
implant.This is especially important in
women who have thin skin and minimal breast tissue who want saline implants. Another
advantage of submuscular placement is a lower incidence of capsular
contracture.This phenomena results in
hardening and distortion of the breast.Patients can also have significant pain with capsular formation.Capsular contractures can occur with the
implant in either position but the incidence is higher when the implant is
placed on top of the muscle.For these
reasons, submuscular placement gives a more natural look in most areas. Placement
of the implants on top of the muscle should be considered in female body
builders who have large muscles which can distort the implants during
contraction.In women with breast sag,
implants can be placed on top of the muscle to avoid a breast lift and
scarring.Every
patient should be considered individually.It’s important that you meet with a board certified plastic surgeon who
can help you obtain your aesthetic goals.

It's a great question. I strongly prefer under the muscle implants because the muscle provides another layer of camouflage for your implants. The muscle contours the top of the implant to give it a more natural slope and implants under the muscle have a decreased risk of scar tissue forming around the implant (capsular contracture). Although an implant on top of the muscle can be a good choice for some women, for very thin women there is not enough camouflage for the implant to look natural. When considering breast augmentation make sure you find a board certified plastic surgeon who will take the time to answer all of your questions and explain all of your options, so that you can decide if breast augmentation is right for you.

Thank you for your question. Below I've provided descriptions of each of the breast implant placements. If you'd like more detailed information and a diagram to explain the different implant placement options, you can take a look at my Guide to Breast Augmentation on my website in the web reference below.Submuscular implant placement: Dr. Zuckerman would make the pocket completely underneath the pectoralis major muscle. It is the most common placement he does, and it is also the most common placement for breast augmentation nationally. It is a simple placement, with a relatively bloodless dissection plane upon implant placement. This placement puts good tissue over the implant, and there is some thought among plastic surgeons that is creates less propensity for capsular contracture.
Subglandular implant placement: Dr. Zuckerman would make the pocket underneath the breast gland but on top of the pectoralis major muscle. This placement has fallen out of favor somewhat, but it is a matter of preference for the surgeon. If the patient has a very muscular chest wall such that when flexing, the implant may move significantly, Dr. Zuckerman might recommend avoiding the submuscular placement and to use sublandular. To some extent, this is also true for those with very little starting breast issue. This is the original implant placement location and was favored in the 1980's.
Dual-plane implant placement: Dr. Zuckerman would make the pocket under the pectoralis major muscle, similar to a submuscular placement, and then free up the interface between breast gland and the muscle so that the breast implant slides. In this placement, the breast implant contacts the bottom part of the breast gland, which hinges the breast mound & tissue to give a little bit more of a lift out of your augmentation. There are three variations of this technique depending on how much of the interface vertically is freed up, and which variation to choose depends on how much lift you would like to achieve. However, this placement cannot be used in place of a mastopexy.

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!

Submuscular placement may be more uncomfortable the first few days following surgery. The possible benefits of submuscular placement are that it may result in less palpable implants, less capsular contracture, and it will make it easier to image the breast with mammography. The appearance may be more “natural” for patients who are very thin. Subglandular placement may make your surgery andrecovery shorter and you may have less discomfort. This placement may provide a slight “lift”. Subglandular placement may result in more palpable implants, more capsular contracture and more difficult imaging of the breast with mammography. This placement is often recommended for those patients with sagging, but do not want a breast lift (mastopexy) and for tubular breast deformity