Over or Under the Muscle? So Confused! (photo)

Most surgeons in the USA using modern techniques would advise you have a sub muscular augmentation. This is shown in the three doctors who recommended this. Implants above the muscle have more visibility issues and a higher risk for capsular contracture. Is the last surgeon much older than the others? This may represent a practice that is using older techniques.

In my opinion, implants should be placed under the muscle with only rare exceptions. The exception might be a severe tubular breast deformity. you can certainly obtain a very natural result with a sub muscular augmentation and mammography will be more effective with the implant under the muscle.

Thank you for your question. In my own practice I favor under the muscle implants. It has been my experience that under the muscle looks more natural and tends to hide the implants better specifically in a slender patient such as yourself. There is clear evidence that implants under the muscle have lower rates of capsular contracture and infection. Under the muscle will also provide you with a better mammogram when the time is appropriate. Lastly, should you need a lift or tightening in your future after childbearing, under the muscle preserves the blood supply to the breast better and makes lifting safer when necessary. Best wishes.

For women with the size breast and body shape like in the photo I would generally recommend under the muscle. It will reduce the incidence of capsule contracture over the long term (10-20 years from now) and will help to give you a "softer" look and reduce the chance of being able to see ripples or wrinkles. This is especially  true the larger the implant you want. But good results could certainly be had with a subglandular implant. There is not any right or wrong.

There are pros and cons to both positions and each doctor has his/her own preference with regards to where they like to place breast implants.  If done properly, either position should give you a natural look.  I started my career putting all of my implants above the chest muscle because my dad did that for forty years.  He said that that was where the breast tissue was and that was where it would look and behave more like real breast tissue.  That was true.  The downside of placing implants above the chest muscle is that 1. there is a higher risk of forming capsular contractures, a thickened scar tissue capsule that can form around the implants causing the breast to become firm or distorted.  One theory is that capsular contractures form in response to bacteria and bacteria live in breast tissue.  By placing implants below the chest muscle, the muscle forms a barrier between the implant and the breast tissue where the bacteria may live.  2. If you use saline implants above the chest muscle, there is a greater chance of feeling/seeing ripples/wrinkles in the implants.  Again, placing implants below the chest muscle gives another layer of coverage over the implants and lessens this risk.  Despite the fact that it may take longer for the chest muscle to stretch and soften, I have changed my philosophy.  I now put almost all of my implants below the chest muscle (don't tell my dad!).  It takes longer to reach your end point but I think it is worth the extra time.  Based on your picture, I would probably suggest putting your implants below your chest muscle too.

I would also recommend submuscular placement for the same reasons as most plastics surgeons on here. The implant coverage is superior and the complication rate lower. There is a rare person for whom recommend subglandular implants. I would recommend getting additional opinions if you are still confused and ask the surgeon about your concern. Ultimately, finding a surgeon is a personal decision and you need to find someone you trust and develop a relationship with . Ultimately, not sound patronizing, it is best to let your doctor guide you into making the right decision, just as you would with any professional.

I usually place implants under the muscle especially in thin patients.  This gives more soft tissue coverage in the upper pole.

Thank you for the question and for providing the photograph.  It looks like your ribs are fairly visible and in this situation under the muscle is best.  It is hard to give definitive answer without examining you in person.  The decision also depends to some degree on which implant is being used.  I have used shaped implants, which ripple less, in a fairly small volume, on top of the muscle in patients with thin tissues but this decisions really vary patient to patient.  In thin patients with little soft tissue coverage over the implant in the upper, inner area the risk of implants on top of the muscle is that you will see the implant edge or rippling.  Hope this helps.

Tracy Pfeifer, MD, MS

If you are athletic and like to do chest workouts, you'll hate submuscular augmentation.  When you flex your pecs, your implants will move like 2 puppies fighting under your shirt.  Over time, your pecs will dislodge the implants downward and laterally.  If you don't do much in the way of chest workouts, then go under the muscle.  My website has extensive info on this topic as well as videos that explain the pros and cons.  The sit  also a lot of other breast aug options you should consider prior to your procedure. 

In general, in a slim individual like yourself, I tend to agree that under the muscle is the best choice for the reasons mentioned previously. In someone like yourself, the only benefit of over the muscle might be that the implants would be closer together and you would have more cleavage. It's hard to see from your photograph whether this would be an issue. If cleavage is an issue, then it is still possible to go under the muscle, and cleavage can be improved with additional fat grafting over the implant in some cases - known as composite breast augmentation. There is no absolute right and wrong in breast augmentation, there are simply pros and cons of each approach that need to be considered when making a decision. We also like to use Vectra 3-D imaging to help patients visualize the differences in appearance with different approaches.