Under the Muscle Vs. over the Muscle?

Thank you for your question. Although there are advantages to placement of breast implants beneath the chest muscle, as discussed by other physicians answering this question, depending on the shape of your breasts, under the muscle placement can not always the done alone.

If after pregnancy your breasts have sagged, and the nipple and areola are below the inframammary crease, that is the fold underneath your breast, then placing breast implants under the chest muscle may result in the nipple areola being pushed further down and creating an unusual appearance called the "snoopy deformity."

If breast ptosis or sagging breast is present a breast lift or dermal mastopexy must be performed first to restore the nipple areola to a proper location before breast implants can be placed beneath the chest muscle. Some surgeons do both of these operations at the same time although many prefer to do the breast augmentation first, allow the implant to settle and then do the breast lift as a second procedure 3-6 months later.

In patients who do not want to have the scarring associated with a breast lift and if the breast ptosis is not too severe, some surgeons prefer to place the breast implant under the breast gland and over the muscle which allows the implant to settle or fall down into the breast and avoid the "snoopy deformity"
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These issues are discussed further in the link to the article below.

Be sure to consult a plastic surgeons who are certified by the American Board of Plastic Surgery, experienced in cosmetic breast surgery and to have an excellent reputation in your community.

You have a lot of options when restoring breasts after pregnancy and breastfeeding.  Without seeing you, or at least a photo, it is hard to tell which option would be best for you.  Because you mention sagging, I would encourage you to explore your breast lift options in addition to breast augmentation.  In general, if you have sagging breasts and a breast implant is placed under the muscle WITHOUT performing a breast lift, you will be left with a double bubble - the implant will sit securely under the muscle and then your breast tissue will continue to sag below.  Placing an implant on top of the muscle without a lift allows you to increase volume, avoid the double bubble, but will NOT correct the sagging.  Additionally, breast implants placed on top of the muscle are usually more visible, more easily felt and they can interfere with mammography.  I try to avoid placing implants over the muscle (subglandular) whenever possible.  A dual plane approach is a nice "happy medium" for many women with MINIMAL sagging (usually women whose nipple is at - not below - the inframammary fold).  With the dual plane approach the implant is placed partially under the muscle, but the lower portion of the pec muscle is freed from the chest wall allowing the implant to settle nicely into the breast envelope.  If you have more than minimal sagging, a breast lift with implant (augmentation mastopexy) may be your best option to create firm, perky breasts with increased volume.

It's hard to say why your surgeon recommended over the muscle without photos or a physical exam. But under the  muscle is typically recommended as it's better for mammograms, camouflages the imperfections of the implants because there is an additional layer covering the implant and reduces the risk of hardening.  Perhaps see a couple other board certified plastic surgeons and go from there.  ac

Unfortunately, you have not provided any photographs but describe yourself as a saggy B.  If the implant is placed in front of the muscle, the additional weight will stretch the saggy envelope even more and you will be dissatisfied.  There is a new technique called Breast Augmentation with Mini Ultimate Breast Lift.  Using only a circumareola incision it is possible to reshape your breast tissue creating upper pole fullness, elevate them higher on the chest wall and more medial to increase your cleavage.  Through the same incision, implants can be placed.  Aligning the areola, breast tissue and implant over the bony prominence of the chest wall gives maximum anterior projection with a minimal size implant.  Small silicone gel implants placed retro-pectoral look and feel more natural, are more stable, less likely to ripple or have complications needing revision. 

Best Wishes,

Gary Horndeski, M.D.

As I discuss in my book, there is no such thing as best. It is not that one technique is better than another, but that each has benefits and risks. You need to review the pros and cons of each technique. In general, over-the-muscle is more natural is the sense that that is where the normal breast tissue resides. The implants will general move more naturally which why many exotic dancers prefer this technique. Under-the-muscle implants tend to be thought of as more safe since the risk of hardening is less and the breast tissue is protected from the implant in part by the muscle layer. Mammograms tends to be easier to obtain because of the lower rate of hardening. However, this is in the ideal situation with ideal size fit and ideal level of softness. Over-the-muscle implants can becomes very unnatural-looking when they get hard or reveal rippling and under-the-muscle can  look and feel very natural when there is an ideal size fit.

Discuss all the pros and cons with your surgeon. The choice between saline and silicone also changes the risk factors. My philosophy is that breast augmentation must be highly customized for each patient and that decision usually need to be made over multiple consultation visits.  

Robin T.W. Yuan, M.D. 

The ideal pocket, or the placement of the implant varies greatly between women.

Generally speaking, under the muscle is recommended to woman after breast feeding because they have lost upper pole volume and going above the muscle will lead to implant visibility. The benefits of going under the muscle is to camouflage the top of the implant by having an extra layer between the implant and the skin.

Your surgeon may be trying to avoid a breast lift.  A photograph would be needed to evaluate your breast and determine if you would do better with a mastopexy and a breast augmentation.  

Both positions are accepted, but I and many surgeons prefer to place implants under the muscle.  Cosmetically the result usually looks more natural.  From a medical standpoint, positioning under the muscle makes mammography easier to perform and lowers the rate of capsular contracture.  The real question for you relates to your "saggy" breasts.  Often a breast lift (mastopexy) is necessary to remodel the loose breast tissue and to remove excess skin.  Please be sure you have discussed this with your plastic surgeon.

It is impossible to tell without a picture but i like under muscle +- a lift. The muscle helps to hide the implant and prevent rippling. Over the muscle is not the wrong choice, just another opinion.

Hello there and thank you for your kind question

The key term you used here is 'saggy' and as I am sure other surgeons will mention, if you do not have an associated uplift to cope with the excess skin you may have a less than ideal result if you go under the muscle. You obviously have an expanded skin envelope following breast feeding and this needs to be filled out adequately. The best way to do this is by going on top of the muscle. I am sure your surgeon has also discussed the limitations of this method too. Good luck!

Paul Banwell