Under the Muscle Silicone or Over the Muscle Silicone?

I am about a 32a from my PS measurements. The only other measurments i can remember is 12 on both sides.. I have alot (i feel) of loose skin from swelling to a 34c while nursing. My PS recommends going above the muscle with silicone but i'm concerned it will not have a very natural look or my skin may not be strong enough and the implant will bulge out at the bottom of my breast. Any thoughts? I'm trying to shoot for going back to the 34c size i was while nursing.

Doctor Answers 18

Under the Muscle Silicone or Over the Muscle Silicone?

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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. Very slightly less tissue may be visualized with subglandular implants, but not very significant.

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!

Breast implants placed under the muscle will do better, longer, and usually softer

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Breast implants placed in the submuscular plane (under the muscle) gives you a much more natural appearance in the upper pole with a smoother transition from the chest and rib cage to the breast projection.  Also, the added layer of tissue in the form of the pectoralis muscle will help make the entire breast look and feel more natural.  Under the muscle implants also have been shown to prevent capsular contracture versus implants over the muscle.  In summary, there are very few reasons why breast implants should not go under muscle.  For first time breast augmentation, under the muscle implants are usually the rule than the exception.

Under the Muscle Silicone or Over the Muscle Silicone?

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There are situations where placing the implant above the muscle is warranted. Personally I like placing the implant beneath the muscle for first breast augmentations. I like this approach because I feel that having the muscle over the implant adds tissue and helps decrease the long term effects of rippling. I do not know the quality of your skin but if it is thin this is another reason to place the implants below the muscle. It depends on the size of the implant that you desire but if the breasts are very droopy, which your so not appear to be, then sometimes patients need a lift as well and there are situations where placing the implant above the muscle will give a slight bit more lift than below the muscle and avoid a lift. My opinion is if a patient needs a lift, I do not try placing them above the muscle to avoid incisions. If you need a lift, you need a lift and you get more incisions. From the looks of your photos you appear to have natural shaped breasts with minimal droop. Your nipples are wide apart and the left breast appears to be slightly smaller. I point out these issues because they will be more apparent when you are augmented. My advice is if you are unsure of your surgeons suggestions just see another surgeon for a second opinion. If you like your original surgeon that does not mean you can not go back to them and have your procedure done. This is your operation and if you want it placed below the muscle just tell your surgeon. All of us on this forum can tell you to do it the way we recumbent, however none of us have seen you or examined you, so your surgeon may see something we do not. I almost never place implants above the muscle in a sub glandular pocket for a first time augmentation. Hope this helps.

Implant placement

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When I was just getting started 16 years ago I would have agreed with going on top of the muscle.  Since then I have seen too many patients with bad results and sagging of the implant from lack of support.  I would recommend going under the muscle and usually in a dual plane as other responders have described.  Make sure your "plastic surgeon" is certified by the American Board of Plastic Surgery.


Gary Hall,MD 

Gary Hall, MD (retired)
Kansas City Plastic Surgeon

Sub Muscular Versus Sub Glandular Breast Implant Position?

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Thank you for the question.

I think it is in your best interests (and that of most patients seeking breast augmentation surgery) to have implants placed in the “dual plane” sub muscular position.  This 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.

Best wishes.

Over or under the muscle?

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I almost always recommend under the muscle unless you already have implants in a different pocket.  There are fewer potential problems in that location. Good luck.

David Stoker, MD
Los Angeles Plastic Surgeon
4.8 out of 5 stars 60 reviews

Under or Over the Muscle for Silicone Gel Breast Implants?

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You have normal breasts and a lean figure. Really you can have your Breast Implants placed either under the muscle or over the muscle.

Because you have had children there is a slight amount of breast sag. The risk of under the muscle is that if your muscle is high it could push the breast down and create a “snoopy deformity.” If this is the case then under the breast gland would be a better choice.

Ask the surgeons who recommended under the muscle if they feel there is risk of Snoopy Deformity. In my practice I ask my patients to be prepared for both options and allow me to decide which is best once I have developed the pocket and can evaluate muscle position. I do a Bi planar approach which makes this possible.

Silicone Over or Under the Muscle?

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In your individualized case I would put the implants under the muscle since your figure is lean.  In a case where there is more loose skin to fill then you would consider putting the implant above the muscle.

Under or over the chest muscle with breast implants

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There are pros and cons to both positions.  Above the chest muscle is where the breast tissue is located and therefore where the implant will behave more like breast tissue.  The downside is that, with a saline implant, ripples and wrinkles are more likely to be felt/seen when placed above the muscle.  Also, there is a higher risk of capsular contractures (scar tissue that can form around an implant causing the breast to feel firm or distort the way it looks) when the implant is above the muscle.  The muscle provides an extra layer of coverage over an implant which helps conceal ripples/wrinkles.  It also massages the implant as you go through your daily routines and minimizes the risk of capsular contractures.  There is also some suggestion in the literature that it is easier to perform and to interpret mammograms when the implants are placed under the muscle.  The downside of under the muscle placement is that the muscle does not stretch as easily as breast and skin so it may take longer to reach your end point with regard to shape and softness.  It may also mean that the recovery may be more uncomfortable than above the muscle placement.  The implant will also be under the control of the chest muscle.  If you flex the muscle, it will cause the implant to move unnaturally.  Having said all of that, I think most plastic surgeons and patients prefer placing implants under the chest muscle if the patient is a good candidate.

High profile implants placed in the subglandular position may look good at first but will likely wear on your tissue over time.

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A word of caution.  High profile implants placed in the subglandular position may look good at first but will likely wear on your tissue over time causing tissue stretching, thinning and lead to implant rippling and being able to feel the implant.

To see what the best options are for you, see two or more board-certified plastic surgeons in your area for a full and complete evaluation to make sure you are a good candidate and that it is safe for you to have surgery.  I hope this helps.

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.