Under Vs over the Muscle for More Natural Results?

I'm currently a big 'A', small 'B' cup, my height is 5'5.5", slim body frame and weigh about 119lbs. I'm 30 and have 2 children who were both breast fed. I would like to be a full 'C' cup, I've recently been to see a consultant who has suggested he will insert 260cc textured Silicone breast implants (High profile) over the muscle. Does this seem ok?

Doctor Answers 20

Breast augmentation under versus over the muscle

In general, most of us would agree that under the muscle is preferred in most cases, but you should know that for the right patient with the right anatomy, you can get a nice result with the implant placed above the muscle as well-- it really just depends on the surgeon's judgement, style and experience, and combining that with what your goals are.

I would speak to at least one or two more plastic surgeons in your area and go with the one you feel the most comfortable with-- this will give you the best chance at a nice result.

Good luck!

Dr. Salemy

Seattle Plastic Surgeon
4.9 out of 5 stars 149 reviews

Unless you are an extreme athlete put your implants under the muscle!

Dear Dufu,

It is generally agreed that the best long-term results occur with under the muscle placement of breast implants. The implants are better protected, rates of capsular contracture are typically lower, and if you have saline implants or are very thin, rippling/waviness of the implant is less detectable. I typically only put implants over the muscle if patient use silicone implants and are extreme athletes (eg. body builders, martial artists, heavy weight lifters, etc.) The reason for this is that the pectoralis muscles in these women are so strong that they push the implants down and out from the center creating a large gap and breasts that are too low. Also, if they are in competition gear every time their muscles flex, the implants move unnaturally. The average woman does not have this concern or goes to the gym and works out like most of us (not super aggressively.) You seem really tiny, so I would recommend that under the muscle placement be entertained.

Good luck,

Dr. Shah

Manish H. Shah, MD, FACS
Denver Plastic Surgeon
4.8 out of 5 stars 56 reviews

Why subpectoral (under the pec muscle) implants

Your instincts are correct. Breast implants today should be under the pectoralis muscle for a number of reasons but one of them is to pad, protect, and blend in the implant so it looks like a natural breast and not an implant under a breast. This is not just a choice thing that's up to the whim of the patient or the surgeon. It's based on decades of experience with breast implants.

In my opinion, a surgeon who is still putting breast implants above the muscle, doesn't know how to position implants properly under the muscle. Implants have to be sized, positioned, and filled (if saline) properly. The objections expressed by the surgeon you mentioned are not true for a properly done procedure. There should be no long term consequences to the pec muscle, and the only trade-off for this is increased movement of the breast when the pec muscle is flexed. This is an issue for only a small number of show body builder women.

It is possible to get an initial satisfactory result with a gel-filled implant placed above the pec muscle but it is likely to eventually be noticeable and all the long term advantages have come down on the side of sub-pectoral placement.

I would add that there is no apparent advantage to a textured surface implant except to try to lock it in place if it's not round. Most situations do not need an implant that is not round. There appear to be several disadvantages to the textured surfacing over the long run.

Scott L. Replogle, MD
Boulder Plastic Surgeon
4.0 out of 5 stars 1 review

Dead muscle?

I'm not sure I agree with what you've been told but there are many different opinions in the operation that you're seeking.

I don't think you'll be a full C cup in 260cc implants, even subglandular. Committing to a cup size can be disappointing. The size may be smaller than you are expecting -- it's not easy to know what you think a full C cup is. I do however think that the size you've been suggested will look great on your body. It is a very tasteful size selection and your ABPS Board Certified plastic surgeon see's that. You should try on that size implant in a bra with a fitted shirt over it (your consultation may have provided that experience). It will appear similar to the end result in clothing.

The muscle wastes some inferiorly when it covers the implant, but it doesn't die. The fact is that you're pretty thin, so unless you're very muscular it is already a thin muscle and it won't make too much of a difference in soft tissue coverage but above the muscle your risk of capsular contracture is higher. What you are reading is correct, submuscular placement is the most popular placement of an implant due to the best longevity demonstrated on countless clinical studies. The subglandular position was the original placement of implants but after enough experience this positioning was only used under certain circumstances (adequate breast tissue coverage, body builders). Most agree that submuscularly, implants age better.

Ricardo A. Meade, MD
Dallas Plastic Surgeon
4.9 out of 5 stars 120 reviews

Over the muscle vs under the muscle

The benefits of placing breast implants below the muscle very often outweigh placing them above the muscle.  A significant advantage is the reduction in the risk of capsular contracture (hardening) with submuscular (below muscle) placement of implants.  Placement under the muscle can also create a softer, more natural contour of the upper breast, especially in very thin women.    The problem with poor tissue “redraping” of moderately droopy breasts over implants placed below the muscles was  solved by the “dual-plane” (implants placed half above and have below the muscle) technique of breast augmentation.  One of the benefits of placing breast implants above the muscle is that upper body strength can be maximally preserved using this technique.  This is especially true and important for female body builders and for extreme atheletes who rely on upper body/chest strength and weight training.

Paul Fortes, MD
Houston Plastic Surgeon
4.0 out of 5 stars 11 reviews

Under vs over the muscle?

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. You may want to consider above if you work out quite a bit. 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 26 reviews

Implants - Under the Muscle Vs. Over

Depending on the implant type and incision, each placement has their benefits. The possible benefits of #submuscular (under the muscle) placement are that it may result in less palpable implants, decreased risk of capsular contracture, and easier to image the breast with a mammogram. Under the muscle placement is recommend for women are are very thin with very little breast tissue. The partial muscle coverage will hide the implant better and help avoid visibility of any implant imperfections such as rippling. The appearance will also look more natural.

This #sub-glandular #placement placement (under the breast tissue in front of the muscle) may allow for a shorter surgery and recovery with less discomfort. This placement can provide a slight “lift.” #Sub-glandular placement can result in more palpable implants, increased risk of capsular contracture and more difficult imaging of the breast with mammogram. This placement is often recommended for those patients with mild breast sag, but do not want a breast lift (mastopexy) and for tubular breast deformity.

The #Dual-Plane placement method is a more current technique most often used when there is mild breast sag and the patient does not want a breast lift. The breast tissue and muscle are partially separated to allow the breast tissue to sit in a better position. Dual-plane can be discussed further during the consultation should breast sag be of concern.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 110 reviews

Under Vs over the Muscle for More Natural Results?

Thank you for the question.

There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”. 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 breast implants 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.
Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,498 reviews

Breast Implants Position

The term 'sub-pectoral' or 'sub-muscular' is somewhat misleading, as implants placed under the pec major are only partially covered by the muscle. The pec major covers the upper/medial half of the breast area, so a 'sub-pectoral' implant is truly subpectoral only in the upper and medial aspect of the augmented breast, while the lower and lateral aspect of the implant is actually in a sub-mammary position. Because sub-pectoral implants are, in reality, both sub-pectoral (upper/medial breast) and sub-mammary (lower/lateral breast), this placement has more recently been referred to as a 'dual plane' approach to breast augmentation.

There is also 'total submuscular' implant placement, in which the implant is positioned behind the pec major and the serratus anterior muscle, so that the entire implant surface is covered by muscle tissue. This is not commonly done for cosmetic breast augmentations, but has been used for breast reconstruction using breast implants.

There are a number of compelling reasons for selecting subpectoral placement over submammary placement. The most significant is that fact that radiologists have indicated that it is easier to image breast tissue by means of mammography when the implant is subpectoral. The pec major also provides an additional layer of tissue to conceal breast implants in the 'social aspect' of the breasts - that part that is easily visible in swimsuits and lower-cut clothing. Additionally, the pec major is quite effective at flattening the upper pole of a breast implant so that a natural slope for the upper aspect of the breast is created.

Implants placed on top of the pec major tend to look very convex in the upper pole. The breast begins quite 'abruptly' in the upper aspect of the chest, and the appearance is therefore distinctly unnatural. Submammary implants are also more likely to have visible implant folds and ripples in the cleavage area. Another consideration is the fact that there is some evidence which suggests that the risk of capsular contracture may be lower with subpectoral implant placement. Even if the risk of contracture is the same, a mild contracture tends to be less noticeable and therefore less of a problem for the patient when the implants are in a subpectoral position.

Submammary placement may produce a reasonable result for fuller figured patients with larger starting breast volumes, as the larger amount of natural subcutaneous fat and breast tissue helps to conceal the implant contours. The problem is that as breasts age, they tend to deflate - especially in the upper pole. So what was adequate implant coverage in the cleavage area at age 27 may be inadequate coverage at age 37, and implant folds and ripples gradually become visible. So subpectoral placement is the best choice for both the short and long term.

'Sub-fascial' breast augmentation is also possible. Fascia is the term for a sheet of connective tissue made of collagen, and the pec major has a fascial covering as most muscles do. Breast implants can be placed behind the pec major fascia only, rather than behind the entire muscle, however this approach is not widely used. The pec major fascia is a relatively thin layer of tissue, so it is not nearly as effective in concealing breast implants as the actual muscle itself. Partial sub-fascial placement can be useful in some breast augmentation revision surgeries, where variations in pec major origin or incorrect release of the pec major has resulted in significant distortion of breast appearance when the muscle contracts.


Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 120 reviews

Breast implants should be placed under the muscle

Most surgeons would advise against placing breast implants above the muscle. The opposite is true; most surgeons place breast implants beneath the muscle. This is performed for three basic reasons:

1. By placing the implant beneath the muscle, the muscle camouflages the implant to some extent so your breast looks more natural and less circular.

2. The second reason is that it is easier for a radiologist to read a mammogram when it is below the muscle.

3. The third reason is that it reduces the complication rate for capsular contracture.

With respect to your consultation, I would suggest a second opinion. Namely because most surgeons no longer use textured implants routinely. Textured implants were at one time thought to reduce capsular contracture complications. This is generally felt no longer to be true.

Phillip Chang, MD
Leesburg Plastic Surgeon
4.5 out of 5 stars 9 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.