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

Doctor Answers 13

Under muscle vs Over muscle

I would say that most plastic surgeons in the United States place breast implants below the muscle or submuscular. I favor this position as well in most cases. The muscle under the breast does not completely cover the implant.  It covers the top half or maybe the top third of the breast implant in most cases.  Some plastic surgeons refer to this position as partially submuscular, which is more accurate.  In some cases, it is referred to as "dual plane" which is another variation.  They all serve the purpose of providing additional coverage over the breast implant which is especially important in the upper chest to give a smooth transition in the upper chest/breast area.  Also it will prevent visibility of the implant and helps to camouflage rippling and wrinkling of the implant. This is especially important in women with low percentage body fat.

The downside is more discomfort after surgery, which I have not found to be an issue; the possibility of movement of the breast implant with contraction of the muscle which is rarely a complaint unless the movement is significant and the woman is a body builder who competes. Mammography may be facilitated if the implant is under the muscle.

The alternative is over the muscle or subglandular. This may be reasonable in women with more breast tissue and/or greater percentage body fat since they have more tissue for coverage of the implant.   Also, some women with a mild degree of droopiness of the breast may benefit from the subglandular position. (In some cases the dual plane technique is used for this purpose as well.)

There can be less discomfort after the subglandular procedure.  There is a slightly greater chance of capsular contracture with silicone breast implants over the muscle.

Thank you for this question and I hope you find this information helpful and good luck.

Fort Myers Plastic Surgeon
5.0 out of 5 stars 43 reviews

Breast Implants over or under the Muscle?

The positioning of breast implants above or below the pectoralis muscle is a decision that will likely influence the outcome of surgery from most patients who undergo breast augmentation surgery. 
The submuscular positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look  of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability  of the implants (which may increase with time, weight loss, and/or post-pregnancy changes).
The submuscular positioning  also tends to interfere with mammography less so than in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position.
As you can tell from this description,  I prefer the use of the sub muscular ( dual plane)  for most breast augmentation patients.
I hope this helps.

Difference between Over and Under the Muscle Breast Augmentation

No breast implants are perfect. A common weakness of ALL breast implants is their forming folds and rippling. To hide these ripples well, the woman's chosen implants are measured to be f a diameter which is covered by her current breast tissue. If this is ignored and an "A to a full D" augmentation is performed, ONLY the top of the impant is covered by breast tissue and te entire periphery and it's ripples are visible and palpable along the entire 360 degrees circumference. 

Placing the breast implant under the muscle under the breast  maximizes the amount of implant coverage and maximally reduces ripple visibility. In addition, placement under the muscle is associated with  a lower ncidence of hard scar formation around (capsular contracture) around the breast implants. 

Peter A Aldea,MD

Peter A. Aldea, MD
Memphis Plastic Surgeon
5.0 out of 5 stars 85 reviews

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Sub muscular vs Sub Glandular placement

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

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 90 reviews

Both options have advantages and disadvantages...

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.

Submsuclar vs submammary

SUB-MAMMARY POCKET (over the muscle)

The implant is placed over the chest muscle, under only the breast tissue.
- good for women with more of their own natural breast tissue so the implant can be hidden better. Also good for tuberous breasts.

SUB-PECTORAL POCKET - Dual Plane (under the muscle) - more common

The top part of the implant is placed under the chest muscle and the bottom third is covered by breast tissue.  
-creates a natural teardrop shape. The implant is better covered so it's better for women with less of their own breast tissue. Makes mammograms easier to read.

Making Good Decisions About Implant Placement

There are two optimum implant placement options: subglandular (between the pectoral muscle and breast tissue) and submuscular (under the pectoral muscle). Implant technology is not unique to placement. As an example, the new Gummy Bear implants may be placed over or under the muscle. Implant placement is one of the most important decisions you and your board-certified plastic surgeon will make as your care treatment takes shape. 

Of these two placement options, submuscular is generally the preferred approach. Medical data supports this - as does my experience (15 years + with a specialty in breast surgery). Submuscular placement reduces the risk of capsular contraction, rippling, malrotation and infection. Additionally, most radiologists will add that submuscular placement improves mammography; it is less likely that the implant will obstruct clear imaging of the breast tissue.

Your research on implant placement may note that greater recovery time is needed for submuscular placement. Please know that if your surgeon is skilled, additional recovery time will not be required. In my practice, for example, patients resume normal activity in less than a week’s time and rigorous exercise in as little as two weeks. Generally, simple Ibuprofen is used for pain management.

As your research continues, you may hear about the so-called sub-fascial implant placement. I would caution that this is more "marketing buzz" than it is good medicine. Fascial tissue is thin and very fibrous connective tissue that surrounds muscle throughout the body, including the pectoral muscle in the chest. Fascial tissue helps bundle muscle groups, blood vessels and nerves. Anyone who has ever skinned a chicken has seen fascial tissue. It’s that thin and amazingly stubborn layer of grizzly membrane over the muscle and meat. Similarly, in human anatomy, muscle and fascia are bound together. Attempts to separate the fascia and tissue to introduce an implant would be traumatic and ultimately ineffective. No place for an implant!

Good luck to you as your research continues and thank you again for the question.

Peter J. Capizzi, MD
Charlotte Plastic Surgeon
5.0 out of 5 stars 54 reviews

Breast implants over or under the muscle

Thank you for your question. Breast implants under the muscle make it somewhat easier to get mammograms and have a slightly lower incidence of developing a hard scar. The muscle can also pad the implant in thin women to avoid severe rippling.  Women who have enough of their own breast tissue may be a candidate for over the muscle because their own tissue will pad and cover the implant making it less noticable. Both techniques are acceptable but selecting the right technique for the right patient is key. Implants under the muscle do bounce and jump with exercise.  I hope this helps.

J. Jason Wendel, MD, FACS
Nashville Plastic Surgeon
5.0 out of 5 stars 87 reviews

Breast Implants Over or Under the Muscle

Should breast implants go over the muscle or under the muscle - which is better?
An implant placed above the muscle is referred to as 'sub-mammary' (or 'sub-glandular'), while an implant placed under the muscle is referred to as 'sub-pectoral' (or 'sub-muscular'). The muscle in question is the pectoralis major. The term 'sub-pectoral' or 'sub-muscular' is somewhat misleading, as implants placed under the pec major are only partially covered by the muscle. The pec major covers the upper/medial half of the breast area, so a 'sub-pectoral' implant is truly subpectoral only in the upper and medial aspect of the augmented breast, while the lower and lateral aspect of the implant is actually in a sub-mammary position. Because sub-pectoral implants are, in reality, both sub-pectoral (upper/medial breast) and sub-mammary (lower/lateral breast), this placement has more recently been referred to as a 'dual plane' approach to breast augmentation.
There is also 'total submuscular' implant placement, in which the implant is positioned behind the pec major and the serratus anterior muscle, so that the entire implant surface is covered by muscle tissue. This is not commonly done for cosmetic breast augmentations, but has been used for breast reconstruction using breast implants.
There are a number of compelling reasons for selecting subpectoral placement over submammary placement. The most significant is that fact that radiologists have indicated that it is easier to image breast tissue by means of mammography when the implant is subpectoral. The pec major also provides an additional layer of tissue to conceal breast implants in the 'social aspect' of the breasts - that part that is easily visible in swimsuits and lower-cut clothing. Additionally, the pec major is quite effective at flattening the upper pole of a breast implant so that a natural slope for the upper aspect of the breast is created.
Implants placed on top of the pec major tend to look very convex in the upper pole. The breast begins quite 'abruptly' in the upper aspect of the chest, and the appearance is therefore distinctly unnatural. Submammary implants are also more likely to have visible implant folds and ripples in the cleavage area. Another consideration is the fact that there is some evidence which suggests that the risk of capsular contracture may be lower with subpectoral implant placement. Even if the risk of contracture is the same, a mild contracture tends to be less noticeable and therefore less of a problem for the patient when the implants are in a subpectoral position.
Submammary placement may produce a reasonable result for fuller figured patients with larger starting breast volumes, as the larger amount of natural subcutaneous fat and breast tissue helps to conceal the implant contours. The problem is that as breasts age, they tend to deflate - especially in the upper pole. So what was adequate implant coverage in the cleavage area at age 27 may be inadequate coverage at age 37, and implant folds and ripples gradually become visible. So subpectoral placement is the best choice for both the short and long term.
'Sub-fascial' breast augmentation is also possible. Fascia is the term for a sheet of connective tissue made of collagen, and the pec major has a fascial covering as most muscles do. Breast implants can be placed behind the pec major fascia only, rather than behind the entire muscle, however this approach is not widely used. The pec major fascia is a relatively thin layer of tissue, so it is not nearly as effective in concealing breast implants as the actual muscle itself. Partial sub-fascial placement can be useful in some breast augmentation revision surgeries, where variations in pec major origin or incorrect release of the pec major has resulted in significant distortion of breast appearance when the muscle contracts.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
5.0 out of 5 stars 90 reviews

What is the Diff Between over the Muscle & Under the Muscle Breast Implants?Answr

I usually tell my patients that under the muscle gives you a more "natural" look and over the muscle gives more of a "wow" look. Under seems to have less hardening issues but it does have the "Animation effect" where the bottom of your breast tightens with pec flexion. Here in the states we do mostly below and in Brazil mostly above. There are some cases that really do need above the muscle but they are not as common.

John J. Corey, MD
Phoenix Plastic Surgeon
5.0 out of 5 stars 28 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.