Under or over the Muscle? (photo)

OK I have a few questions about these placements. I really want my breast to sag like normal breast, and I don't want them to be perky. I dont want to go over 300cc either. I was hopping to get it through the armpit incision and possibly over the muscle. Ive seen pictures and i think the look more natural over. I want the flatter look too(not such a high profile(not perfect).

Doctor Answers 12

Breast Implants over or under muscle-consult two board certified plastic surgeons

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Thank you for your question.

The answer to your question is not simple.  You do have some sagging of the breast which is called ptosis, which is when the nipple is at or below the crease beneath her breasts.

Statements that there is no place for sub glandular breast augmentation or placing the implant of the breast are inaccurate.

If you place a sub muscular implant in a sagging breast the muscle holds the implant too high and can push the nipple down creating an appearance called a Snoopy Deformity. To avoid a snoopy deformity a breast lift in addition to a breast augmentation is required as bi planar breast augmentation is often insufficient to compensate for sagging.  For patients who have mild degrees of sag or ptosis who absolutely refuse to have a breast lift, a sub glandular breast augmentation beneath the breast gland can often produce a nice result.

I suggest that you see two board-certified plastic surgeons who are experienced at breast enhancement surgery and base your decision on what you learn during the 2 different consultations.


Under vs over the muscle breast implants

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

I choose not to ever place implants over the muscle. Implants over the muscle have a much higher rate of complications (rippling, contracture, pain, excess skin stretching) Trust me, implants under the muscle will eventually give you the look you submitted. Most PS show breast augmentation photos that are only a couple of months after the procedure. FYI, over the muscle breast implants account for the majority of revisions in my practice. I hope this helps you,

Dr. H

Gary M. Horndeski, MD
Texas Plastic Surgeon
4.6 out of 5 stars 230 reviews

Under or over the Muscle?

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
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.   Your statements seem reasonable.  Silicone would likely afford a more natural look, and may be difficult through an armpit incision. 

Hope that this helps! Best wishes for a wonderful result!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 28 reviews

You might also like...

Shaped implants over the muscle

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
First of all the remark that axillary incisions have a higher infection rate, I believe is inaccurate. I have never had an axillary incision infection, knock on wood, compared to the 1% rate for inframammary and a much higher rate thru the nipple.

The recent data out of Brazil shows that the subfascial (above the muscle but below the fascia) with shaped cohesive gel implants has not shown a high capsule rate or visibility even in their thin patients. However, I still believe it is higher.

But in cases where there is droop subfascial will correct better. Less pain too. And there is a virgin pocket to switch to below the muscle later with a lift if needed to switch. The only drawback then is spending more money. Lastly then you wont have implant movement with contraction of the muscles.

That all being said I do 99% below the muscle, but in cases with a larger implant, and droop there is a place for subfascial, especially with our colleagues in Brazil showing low rates of problems.

Under or Over the Muscle for Breast Augmentation?

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

There really is no place anymore for breast implants that go under the breast but not under the muscle.  This has been replaced with the "dual plane" approach, which is half-and-half as the name implies.

If your breast is relatively high in relation to the crease under your breast, then the traditional approach under your muscle is best.  The implant must be concealed in the upper half by the draping of the pectoral muscle or there will be an obvious step-off visible, especially after a couple of years as the skin stretches.  Also, the implant is held up at the bottom by the muscle, which keeps the implant from dropping because it holds it up as gravity tries to bring it down.

But if your breast has some ptosis, then the breast implant needs to be placed a little lower to match the height of the nipple height.  The implant therefore is placed a little lower than the lowest edge of the muscle.  Now the lower half of the implant is under the breast, and the upper half is under the muscle (dual-plane).  You still get the muscle draping in the upper half that is so important.

Gregory Diehl, MD, FACS
Long Island Plastic Surgeon

Breast augmentation -getting it right the first time

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

As you can see from the posted replies there is no one size fits all solution. I would be equally concerned that your areolas are enlarged and the left more so than the right. Also there is more breast tissue at and above the nipple level than below it i.e. the breast tissue is not evenly distributed around either nipple. Although you may be able to correct the tissue distribution via the armpits using an endoscope you can only correct the areola with a skin incision near the areola. If you just put in implants without any breast adjusting procedures it is highly likely that you will be unhappy with the result whether or not you put the implants under or over the muscle.

I hope you realize that this format of posting questions and receiving answers lacks the face to face direct communication required for you to make an informed decision regarding your surgery.

My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.

Aaron Stone, MD
Los Angeles Plastic Surgeon

Under the muscle (a dual plane) will likley give you the best immediate and long term result

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Thank you for the question and picture.  You appear to have thin breasts with minimal breast tissue.  You will likely have less breast tissue as you age and implants that have minimal coverage do not look natural.  By placing cohesive gel implants in a submuscular / dual plane position (covered by muscle for the top 1/2 of the implant and breast tissue in the lower 1/2 of the implant) you will get the natural appearance that you are seeking.  This will give you a very natural breast shape and avoid the appearance of the roundness and rippling that is often seen whan an implant is placed above the muscle in a thin breast.  In addition, the submuscular / dual plane implant position has a decreased risk of capsule formation.  The armpit incision is an option but is associated with some increased complications.  Talk to your PS about the benifits and risks associated with the different incisions and implant pockets.  Together you will be able to come up with a decision that gives you the result that you are seeking.



Scott Barr, MD
Sudbury Plastic Surgeon

So you want over the muscle breast implants

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

There is nothing wrong with a lower profile gel implant over the muscle, and in the late 70's they were the 'standard'. You can get a very nice result and you should not be discouraged. Why under the muscle you might ask? The switch was motivated by much less show through or thinning, lower capsular contracture rates, less ripple, softer upper edge after higher profile implants were introduced, etc. all good things though there is never one answer for all individuals. Avoid shaped implants unless you will stand all the time, and the higher infection rate under the arm is a false scare as well.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Above or below the muscle placement of breast implants??

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
Thank you for the question. For women who want a more natural look to their breasts and have adequate tissue to cover the implant, above the muscle is a good choice, because naturally the breasts are above the muscle. Now with the availability of the shaped implants in the US you can have even more of a natural look to your breasts, with the lower part being fuller than the top. Best of luck!

Dana Khuthaila, MD, FACS
New York Plastic Surgeon
5.0 out of 5 stars 77 reviews

Breast augmentation implant placement

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Dual plane breast augmentation provides benefits of being on top of the muscle and under the muscle at the same time.  The upper portion of the implant is placed under the muscle, which helps to conceal the implant in an area where there is frequently less natural breast tissue for coverage, while the lower portion of the implant is placed over the muscle, frequently helping to provide a more natural contour in that area.

You may also wish to consider that an inframammary incision, placed just above the fold, ends up being on the back of a breast that has a little natural ptosis ("sag"), and is usually not visible when the breast is viewed from the front.  There are advantages and disadvantages to each surgical approach (as well as each implant location), and I would recommend that you discuss them in detail with a board-certified plastic surgeon before making any decisions.

Good luck.

Craig S. Rock, MD
Houston Plastic Surgeon
5.0 out of 5 stars 29 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.