What Are the Pro's and Con's of Implant Placed in Front or Behind Chest Muscle?

I've had silicone implants since 1978. They maintained a natural feel all these years. They've started to leak, One has started to contract and has become hard.I have had consultations with two doctoc's. They have each given me a different replacement proceedure. One, to use a Sientra tear-drop implant along with a breast lift. The other doctor would use the Mentor MemoryGel silicone gel implant, placing it under the chest wall muscle, plus a breast lift. I'm confused as to what to do.

Doctor Answers 10

What are the advantages of going above vs below muscle in breast augmentation?

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When deciding between above and below muscle implant placement, consider the following
Below Muscle: more natural/smoother teardrop shape as the muscle covers the upper part of the implant, muscle provide additional layer of coverage over upper breast implant hiding the outlines and rippling of the implant, and going under has a slightly lower risk of implant hardening/capsular contracture.  The downside of going under the muscle is that when you flex your muscles, the implants get displaced to the sides

Going above the muscle is less painful and has a quicker recovery.  The shape has more fullness up top (more of a push up bra look), and the implant is more visible in V neck dresses.  In very skinny patients the rippling is more visible.  The risk of capsular contracture is slightly higher.  There is no significant movement of implants when you flex your pectoral muscles or when you work out.

Toronto Plastic Surgeon
4.9 out of 5 stars 521 reviews

What Are the Pro's and Con's of Implant Placed in Front or Behind Chest Muscle

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Sub-muscular placement is usually not totally submuscular

The muscle is usually incised inferiorly to create more space

The muscle invariably retracts upwards resulting in the lower third  of the implant to be in the subcutaneous position

Muscle contraction causes compression of the implant and may cause distortion

The muscle does cover the upper pole more effectively,and may be of some benefit in terms of mammography

Placement of the implant above the muscle is usually fine if the tissues are sufficient to support the implant

If the tissues are thin the implant becomes more visable,especially saline implants.The upper pole may collapse and the implants tends to sag with time

It is for these reasons that I now use the subf-ascial placement of implants

Hilton Becker, MD
Boca Raton Plastic Surgeon
4.6 out of 5 stars 15 reviews

Sub Muscular vs. Sub Glandular Implants - Which Is Best For Me?

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Thank you for this challenging question.  I am going to have to make certain assumptions.  First, since your surgery was done with silicone implants in 1978, I will pretty much bet they were on top the muscle at that time.  One implant now has a capsular contracture, therefore, that pocket has been compromised.  Fortunately, it is probably above the muscle, and you want to go sub muscular anyway to decrease the chance of capsular contracture. 
The plastic surgeon who suggested going sub muscular is definitely on the right track.  Secondly, tear drop implants don't work because they rotate, and to keep them from rotating, the manufacturer has textured them which I predict will lead to unfortunate consequences.  Therefore, I would stick with the round, smooth implants recommended by your second plastic surgery consultation.  Since both surgeons recommend a lift and since you sent no pictures, I think it is a reasonable assumption that you need a lift. 
In general, implants below the muscle are better for multiple reasons. 
     1.  You get a better mammogram.
     2.  They statistically stay softer.
     3.  Less chance of rippling because more of your own tissue between the implant and the outside world.
     4.  They have a more natural look since one of the insertions points of the pectoralis muscle is your collarbone, and an implant under the muscle appears to gently come down from the collarbone as natural breasts do. 
Therefore, all in all, I go with consultation #2.

Sub muscular versus Sub Glandular Breast Implant Position?

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Thank you for the question.
Based on the details in your question, I would not be surprised if you are presenting with a complicated situation in regards to your breasts. Keep in mind, that I cannot provide you with precise advice without direct examination and a full communication of your goals (which I would be happy to do).  However, some general thoughts about breast augmentation done in the sub muscular versus sub glandular position may be helpful to you.
There are pros and cons to the placement of breast implants and the “sub muscular” position versus the "sub glandular position”.  There are also pros/cons associated with the use of saline implants versus silicone breast implants. I will try to outline some of the differences here;  you may find the attached link helpful as well.
I think it is in the best interests of most patients seeking breast augmentation surgery to have implants placed in the “dual plane” or 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.
On the other hand,  sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants  seen with flexion of the  pectoralis major muscle)  they can be seen with breast implants placed in these sub muscular position.  Also, the immediate recovery period may be  more comfortable  after sub glandular breast augmentation as compared to sub muscular breast augmentation surgery.
 I hope this helps.

What Are the Pro's and Con's of Implant Placed in Front or Behind Chest Muscle?

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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!

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

Above or below the muscle?

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Breast implants:  “Over or Under?”  What about both?

Simply put, if you are considering breast augmentation, it is likely that you want more beautiful breasts.  My goal is to achieve the most natural and beautiful breast augmentations that I can.  How I achieve that depends upon my skill, experience and judgment.

One of the most important considerations when planning a breast augmentation operation is how I will place the implants with respect to the “muscle,” the pectoralis major muscle on your chest.  Said another way, in what plane will they be located? 


• Breast implants placed below the muscle are said to be in the submuscular, or subpectoral, plane or position

• Implants placed above the muscle are said to be subglandular, or in the plane under the breast gland and over the muscle. 


I find that most people are rarely fully informed about this important subject, so I would like to share with you the way I approach this issue with my patients. There are many reasons why a patient and her surgeon may pick one or the other location for her breast implants.  Typically I advise my patients of the pros and cons of each. Then I give them the final decision based upon their goals and how they feel about the pros and cons we discuss. 


The breast is not naturally a submuscular organ.  Believe it or not, it is more like a physiologically modified collection of sweat glands that develops above the muscles.  As such, it has more to do with the skin than it does with the muscle.  Thus, technically speaking, placing breast implants under the pectoralis muscle is not an anatomically accurate way to recreate a breast. 


Most patients have been told that “under the muscle is always better.” This is the position used most frequently by surgeons so that is the conventional wisdom.  The vast majority of breast implants today are placed in the submuscular plane.  Over the years we have done this for a variety of reasons. The main advantages of placing breast implants under the muscle are: 

1) A more natural appearance of the upper part of the breast is typically obtained as the muscle adds some additional tissue thickness to cover the implant and soften and camouflage its contour. This is why it works despite the anatomical inaccuracy of it all.

2)  The incidence of capsule contracture is less when implants are placed below the muscle for reasons that we don’t fully understand.

3) Generally mammography is easier when there is muscle between the implant and the breast tissue itself. 

The main disadvantages of placing implants below the muscle are: 

1) Contour is not always natural on the bottom of the breast, and the breasts can move abnormally with muscle contraction unless the muscle is released properly.

2) The breast tissue itself cannot always expand to follow the contour of the implant, and this can give rise to later problems such as “double bubble” and “Snoopy breast” deformities

3) Recovery time is sometimes a bit longer and there is a bit more soreness in the chest because the divided muscle has to heal.

Wouldn’t it be great if we could have the best of both worlds?  Eliminate the “or” in favor of the “and!” 

This way of thinking gave rise to the Dual Plane Mammaplasty. This approach to breast augmentation uses both the submuscular and the subglandular planes. It takes the best advantage of both approaches.  The dual plane technique was first conceived to treat women with some laxity in their breast tissue resulting from aging or breast-feeding. This avoided the need for a lift in many instances.  Basically, in the dual plane approach:

• I raise the muscle and position the implant beneath it, just as in a submuscular augmentation. This allows the top portion of the breast implant to rest beneath the muscle, making it a true submuscular implant with all of the advantages that provides.

• On the lower portion of the breast, the part where we really want the breast tissue to “drape around,” or adopt the contour of the implant, I create a subglandular space allowing the bottom of the implant to fill the subglandular plane. The breast then becomes full and round without the tendency to form double bubbles or “Snoopy breast.”


I now use the Dual Plane Mammaplasty technique on all of my breast augmentation procedures because I think it really does produce the most natural and beautifully shaped breasts.

If you need a lift, however, that may affect some of the planning, but in general, the above principles should still be followed to produce the most natural appearing breasts.


Joseph L. Grzeskiewicz, MD
San Diego Plastic Surgeon

Sub muscular conversion of breast implants

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In the face of capsular contracture above the muscle it is common to consider sun muscular replacement plus a lift if indicated.  Unders are felt to give better mammograms, have less scar tissue, and hold up better long term.

Seek A Third Opinion

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Since you have 2 divergent opinions and have not provided photos, I would suggest a third opinion.  I do not like tear-drop implants and almost always place implants below the muscle, but again would like more information to give a definitive answer.

John Whitt, MD (retired)
Louisville Plastic Surgeon

Breast implant positioning

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There is no single best way to achieve a desired result, but each surgeon has a preferred approach. Our website explains advantages, disadvantages, and elements to consider when deciding upon implant positioning.

Steve Laverson, MD
San Diego Plastic Surgeon
4.9 out of 5 stars 50 reviews

Breast surgery options

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There are many different ways top "skin a cat."  So, when you go to different doctors they will often offer different options and solutions.  There are many different reasons for implants below or above the muscle.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 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.