Over or under muscle?

Hi,

Choosing between over or under the muscle implant placement is complex. Firstly, it's essential to understand the terminology: "submuscular" means under the muscle; "subglandular" means under the breast tissue, over the muscle and muscle fascia; and "subfascial" means over the muscle but under the pectoralis fascia. A surgeon's experience and your body type heavily influence this decision. Surgeons often prefer the approach they've had the most success with for similar body types. If you have minimal chest tissue, submuscular placement helps avoid an unnatural, abrupt transition between the chest and breast. However, if you have good breast form and desire a small increase in size and projection, subglandular placement might be suitable. The subfascial approach, offering most advantages of submuscular placement without disturbing or injuring the muscle, is gaining popularity. For those who exercise regularly, over the muscle placement is recommended to prevent "animation deformity," where implants move laterally and inferiorly, potentially causing distortion, displacement, or flipping when contracting upper body muscles. Ultimately, discussing your aesthetic goals, anatomy, body type, and lifestyle with your surgeon is crucial for deciding the best implant placement.

My comments and recommendations are solely based on your text and are subject to change. I always recommend a face-to-face consultation with a specialist to plan the treatment.

Best wishes, Dr. Surmeli.

Dear Pioneering26540,
I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Thank you for your question! Over the muscle placement (subglandular) can create a fuller, rounder look without extra muscle involvement, which can sometimes be ideal for patients looking for a strong, noticeable upper pole fullness. For naturally smaller and leaner patients, there’s a higher chance that the implants may be more visible or feel less natural, especially in the upper part of the breast, which is why visibility can sometimes be a concern for patients with less breast tissue. However, under the muscle placement (submuscular) can provide a more natural look, especially for patients with small breasts and a lean build, as the muscle helps to camouflage the implant. In your case, the choice depends on your priority for either a fuller look with quicker recovery (over the muscle) or a more natural look with minimized implant visibility (under the muscle). Both options can be tailored to give great results, but based on your thin frame and small natural breast size, the recommendation for under the muscle might indeed help achieve a softer, more natural result.

I generally prefer to put the implant under the muscle for several reasons. Probably the most important consideration is how much tissue you have in the upper pole of your breast to hide and soften the implant appearance. If you pinch this area and have about 2 cm of tissue above the muscle, placing the implant over the muscle probably will not lead to issues of implant visibility. But then if a patient loses weight… Visibility may occur.

Whether to place your breast implants above or below your muscles depends upon your anatomy and your wishes and your understanding of the pluses and minuses of each choice. Most surgeons in the United States place the implant underneath the muscle. Many surgeons in Europe, place the implants above the muscle. As a general rule, patients who are thin, have minimal breast tissue and small breasts, are best served by placement of the implant under the muscle so that you gain one additional layer of coverage and camouflage of the edges of the implant. Placement of the implant under the muscle also helps to decrease the rate of capsular contracture, at least within the first 10 years. That said, with meticulous adherence to the 14 step protocol for minimizing capsular contracture that most plastic surgeons follow nowadays, the rate of capsule contracture and implants placed above the muscle as opposed to below the muscle is very close. Best wishes.

Both options come with their own advantages and disadvantages. In general, I would agree that if the breasts and skin are thin, there is a higher risk of visible rippling or deformity when the implant is placed over the muscle. Additionally, capsular contracture, where scar tissue thickens around the implant, tends to occur more frequently with the over-the-muscle technique.
The best candidates for the over-the-muscle approach are typically those who use their chest muscles intensively, such as professional athletes, or individuals seeking a more pronounced, high-cleavage, augmented look.
I hope this helps make your decision a bit easier. Wishing you all the best.

In front if you are interested in a fake look. Also, lower chance of capsular contracture when placed under muscle. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Thank you for posting your question here!I will start by stating that my answer is based on the limited information provided , for a bespoke plan that better fits your needs I would recommend going with a surgeon you trust .
When it comes to sub muscular breast implants, a lot of surgeons choose them for the following reasons ( i will state a few):- if you don't have enough soft tissue overlying your breast, most surgeons will offer a sub muscular breast implant as it will provide an additional layer that can hide the implant and decrease the chances of rippling.- placing the implant under the muscle has been shown in some situations to decrease the chances of capsular contracture.- Placing the implant under the muscle, gives the patient a more natural upper pole slope (less of an implant look at the upper part of the breast)
That being said there are some caveats to placing an implant under the muscle, I will include a couple:- Placing it under the muscle can lead to implant laterization long term (as the muscle contracts it can push the implant laterally)- in individuals who do a lot of weight lifting, they can develop animation deformity (the breast moving with muscle contraction)- in addition to other technical issues such as windowshading etc which are dependent on your surgeons expertise and how much of the muscle they release.
some surgeons choose to place the implant above the muscle for the following reasons (I will state a few):- if you already have plenty of tissue above the muscle- you are looking for a more augmented implant look- might provide some lifting or at least a lifted look - you workout a lot and are at a higher risk for animation deformity.- it's a relatively easier surgery (depending on what the surgeon is used to) and quicker recovery (though both have a relatively quick recovery)
The caveats include:- Higher chance for capsular contracture - An augmented implant look (the upper border of the implant can show)- Higher chances or rippling if you don't have much tissue - less control over the pocket.
I hope this answer helps! best of luck!

In general, breast implants have less long-term complication rates when placed under the muscle. However, instead of giving you a blanket answer favoring one approach, here is an objective, detailed overview of each technique:

1. Over the muscle (subglandular) placement:

- Advantages:

Quicker recovery and less pain.
Easier surgery.
Can lift mildly sagging breasts.
No distortion during muscle flexing (good for athletes).

- Disadvantages:

More visible implant edges, especially in thin patients.
Higher risk of capsular contracture (hardening of implants).
Implants may affect mammograms.
May feel less natural.

2. Under the muscle (submuscular) placement:

- Advantages:

More natural look and feel.
Less rippling in thin patients.
Lower risk of capsular contracture.
Better for mammograms.

- Disadvantages:

Longer, more uncomfortable recovery.
Implants may distort with muscle movement.
Takes longer for implants to settle.

Dr. B.

Thank you for your question. I have been in practice almost 30 years and revisionary breast surgery is a large portion of my practice. I have a whole gallery of chronic changes associated with subglandular breast augmentation. Basically, after a few years the implant slides down the chest wall, and there is significant wrinkling of the breast implant. It is a rare occurrence for me to see a long-term aesthetically good outcome after subglandular breast augmentation. Best wishes to you.