Breast Implants under the muscle vs. over the muscle

What are the pros and cons of each implant placement? Does one cost more than the other?

Doctor Answers 6

Breast Implants under the muscle 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.   Cost should be the same.

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!


Scottsdale Plastic Surgeon
5.0 out of 5 stars 24 reviews

Breast Implants under the muscle vs. over the muscle

Thank you for the question.
There are pros and cons to the placement of breast implants and 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 the sub muscular position.   Best wishes with your decision-making and for an oucome that you will be very pleased with. Make sure that you consider the longer-term outcome ( for example changes in body/breast with time/age) as you make your decisions.

Under v over the muscle

Thank you for your question.

Most plastic surgeons in the United States place breast implants below the muscle or submuscular. I favor this position as well in most cases. The muscle under the breast does not completely cover the implant. It covers the top half or maybe the top third of the breast implant in most cases. Some plastic surgeons refer to this position as partially submuscular, which is more accurate. In some cases, it is referred to as "dual plane" which is another variation. They all serve the purpose of providing additional coverage over the breast implant, which is especially important in the upper chest to give a smooth transition in the upper chest/breast area. Also it will prevent visibility of the implant and helps to camouflage rippling and wrinkling of the implant. This is especially important in women with low percentage body fat.

The downside is more discomfort after surgery, which I have not found to be an issue; the possibility of movement of the breast implant with contraction of the muscle, which is rarely a complaint unless the movement is significant, and the woman is a body builder who competes. Mammography may be facilitated if the implant is under the muscle.
The alternative is over the muscle or subglandular. This may be reasonable in women with more breast tissue and/or greater percentage body fat since they have more tissue for coverage of the implant. Also, some women with a mild degree of droopiness of the breast may benefit from the subglandular position. (In some cases the dual plane technique is used for this purpose as well.)

There can be less discomfort after the subglandular procedure. There is a greater chance of capsular contracture with silicone breast implants over the muscle.

Thank you for this question and I hope you find this information helpful and good luck.

Ralph R. Garramone, MD
Fort Myers Plastic Surgeon
4.8 out of 5 stars 53 reviews

Unders and overs

There are many reasons to place the implant under the muscle and very few to put it over the muscle. Under includes lower capsular contracture rate, better appearance, better tissue coverage over the implant, less rippling, and less stuck on appearance. 

Submuscular

I always prefer sub muscular implant placement. There is better coverage of the implant edges, the rippling is less common, the risk of infection and capsular contracture is lower, the interference with mammograms and breast feeding is less, the look is better, the feel is better. There are no reasons to go sub glandular.

Breast Implants under the muscle vs. over the muscle

Most implants today are placed in a sub-pectoral plane ( commomly referred to as under the muscle) but only a portion of the implant is covered by muscle.  The advantages are more natural look and feel, decreased risk of capsular contracture. Disadvantage is that may be slightly  more uncomfortable post  surgery due to stretching of the muscle.  Sub-gladular ( above the muscle placement) results in a less natural look and in more visibility and palpability of the implant but this is dependant on how much breast tissue you have to begin with. 

Raymond Jean, MD
Philadelphia 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.