Which Breast Implant Placement Gives a More Natural Appearance?

When getting breast implants, what gives a more natural appearance, going under or over the muscle?

Doctor Answers 159

Implants placed beneath the breast tissue only tend to give the most NATURAL results!

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Most women I see in consultation are looking for a NATURAL, not a "done" or fake result of breast augmentation.  I see both professional women who work full-time and full-time Moms, from all over Northern California and also occasionally Canada (my original home!). 

Most are very physically fit, at their ideal weight, and are quite physically active, using the pectoralis major muscles all the time for activities of daily living.  In fact, we ALL use these muscles routinely. 

I believe that NO operation should distort this major muscle of the body and stretch it out over a breast implant.  The potential purported benefits do not outweigh the potential negative consequences, in my mind. 

Breast implants placed behind the breast tissue only ("subglandular") gives the most natural appearance to the breast, even in very thin women.  A subglandular placement avoids the "motion deformity" seen when implants are placed below the muscle ("submuscular" or "subpectoral"), even in women who think they are not that physically active. 

Submuscular implants sit high and wide on the chest, and have a slightly less natural appearance in many women.  This can be demonstrated by pressing the palms of the hands together in front of the body and flexing the pec muscles in front of a mirror. 

Implants behind the breast tissue only also age better than submuscular implants, which tend to keep the implants in a high and wide position as the body ages.  Consequently, the breast tissue "falls off" the implant with time, creating a "snoopy deformity" or a "double bubble" appearance.

I like my patients to follow up with me every year, forever!  This enables me to ensure they are still looking good and feeling good even years after their breast augmentation. 

There are many different surgical techniques in breast augmentation.  I strive to educate my patients about how I choose to do things and why, with numerous before and after photos that are shared in the office on the initial consultation. 

I always try to do "what makes sense" in Plastic Surgery, and select techniques that I would have done to MY own body!

Karen M. Horton, M.D., M.Sc., F.R.C.S.C.

San Francisco Plastic Surgeon

Breast Implants - Behind The Muscles for Natural Results, Lasting Results and Mammography

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Breast implants should be placed in a subpectoral position - it creates a much more natural upper pole appearance, and it makes the breast easier to image by mammography. 

Meticulous pocket dissection to produce a ‘hand-in-glove’ fit for the implants is essential for a natural and long lasting result. View many many photos for evidence that your plastic surgeon has expertise providing natural looking results with breast augmentation surgery.

While the issue of ‘over’ or ‘under’ the pectoralis major muscle receives a great deal of attention, even more important than implant position relative to this muscle is implant position vertically and horizontally on the chest wall.  Please view hundreds of images of breast augmentation before and after images as part of your research.

In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness. 

In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that an implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear ‘bottomed out’, with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast – another situation with a distinctly unnatural appearance.

The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Breast implant pockets that extend too fat laterally will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. If the pockets do not extend far enough laterally, however, the result is an augmentation with an abnormal ‘side by side’ appearance. As it is the lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an ‘hourglass figure’, careful attention must be paid to ensure that lateral breast projection is adequate and appropriate.

Another consideration is that the implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient who is 5’2” will be inadequate for a large-framed patient who is 5’10”. Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast enhancement.

I urge all propective patients to take time, do a lot of research and view many many before and after photographs before selcting a plastic surgeon to perform your breast augmentation. Taking some time to speak to several former patients who have had the same surgery you are considering can also be helpful.

There is a temptation for some patients to look at before and after images they like from a website of a plastic surgeon and take the "recipe" the plastic used Cc's of implants, profile, brand of implants and position. They then take this formula or recipe to another surgeon and except the same outcome. Plastic surgey doesn't work that way.  Often the results are very, very different. 

There is no "recipe" for an ideal breast implant result. The real key is finding a plastic surgeon with exceptional training, experience and attention to detail. Careful pre-operative planning and meticulous surgical technique are essential for breast implant results that are consistently beautiful and natural looking.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Your body is the key

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In my San Francisco practice most of my patients have implants placed under the muscle. Creating a natural looking augmentation has many factors, all of which need to be addressed.

Some of these include (in order of typical importance):

Implant size
Implant shape (high profile, moderate profile, low profile)
Implant position (over, under the muscle)
Implant material
Incision placement

Your plastic surgeon should assess many factors including:
your desired outcome and size
breast volume
skin excess
breast diameter
skin quality
chest wall asymmetries

All of these (and more!) must be considered in creating a natural looking breast augmentation that will meet your expectations.

I hope this helps!

Steven Williams, MD

Silicone implants under muscle give more of a natural look

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This has been interesting reading for me as I am a plastic surgeon who specializes in BA. I perform about 450 such procedures annually. Let me tell you what I have learned. The best way to choose your implant is to forget about cc’s. Let the surgeon do that…it’s his job. What you should do is be able to communicate the look you are trying to achieve and often pictures of other people is a good place to start. There have been many times when a patient has told me they wanted to be a full c and then I see pictures depicting a d cup. It’s not exact but a good place to start. Take a look at the surgeon’s before and after pictures to se if there are sizes which you find appealing. The measurements which we take are guidelines for some of the decisions which we make. They are not exact criteria for the size you should get and neither are the implant dimensions. There are certainly people who have chosen implants smaller than what their chest could accommodate and the corollary has occurred very often, as well. DO NOT LET YOUR SURGEON PICK YOUR DESIRED SIZE. We are not the ones living with it. Unless there is a definite anatomic restriction it may be the time to get another opinion.

Now a few words about implants. Saline are still the most common in the U.S. but are they the best choice? Not in my humble opinion. I believe them to have too much rippling upon palpation. The only positive aspect is that they require a much smaller incision for placement. As for silicone, I find them to feel the most natural. Silicone implants are much different than the ones which were taken off the market in the early 90′s. The shells are much thicker and the silicone gel is much thicker (cohesive). Cohesive is a term for all silicone and is confusing because there are varying degrees of cohesiveness. The old implants were cohesive but in such a state that they would leak. The new implants (cohesive I) will not leak but if cut in half and squeezed it will not return to the original shape. Cohesive II (Mentor Lumera) are much thicker such that they have a jello appearance when cut and will return to their original form after being squeezed. These are available only in textured and tear drop shape. They offer a bit less rippling than the cohesive I but are also a bit firmer and I believe less of an option for purely cosmetic reasons. The last is cohesive III (gummie bear) which are the thickest. I have not had as much experience with these but am a little discouraged by the feel (too firm) and the incision required (long and inframmamary position). The cohesive II and III are much less pliable and require a larger incision as they are not pliable and have memory of form. My last point…there is never a reason to put an implant above the muscle (subglandular) position. It is a setup for problems. It appalls me that some surgeons still do it that way.

The natural looking breast implant

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I strongly concur with Dr. Williams excellent and detailed response.

I offer patient's a simple analogy to illustrate what we mean:

Q: If you take a baseball and you cover it with a silksheet, what will it look like?

A: Like a baseball, you will even see the stitching.

Q: Now if you take that same baseball and cover it with a comforter what will you see?

A: It depends on how thick the comforter is but generally you will see a softly shaped lump.

So now the question is what do you have on your chest, silk sheets or comforters?

The way we determine this is by looking at your chest, if I can see your ribs (under the muscle) then you anatomy will have a hard time disguising the implant whether it is placed under or over the muscle and you are more likely better off with a silicone implant. Another way of measuring this is to pinch your upper chest skin (similar to pinch and inch of your waist on the Special K commercial). If you have less than an 2 cm (under 4/5 of an inch) than you have "silk sheets"

If you have a thicker skin/fat/breast layer that pinches over an inch than you have the option of going under or over.

Now the exception to the rule:

Q: What happens if you change the baseball to a volleyball?

A: All bets are off, whether you put it under or over the muscle it will not look natural.

The last issue is the implant shape. There are some anatomic shaped implants but I have generally found them to produce no significant difference in outcome with the exception of breast cancer reconstruction. However, this is my personal opinion.

Under the muscle almost always better

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I am a big proponent of submuscular breast implants.  They are less like to stretch out the breast and make it droop over time.  They hide the implant and make it look more natural.  They are less likely to interfere with breast exam and mammography, and they are less likely to get hard.  Some surgeons recommend on top of the muscle implants for droopy breasts.  It is true they will fill out a droopy breast better at first.  However, shortly thereafter, they will drag the breast down and it will be more droopy than ever.  Usually, an implant under the muscle is better.

In general, under the muscle gives a more natural result

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We women are incredibly aware of our breast appearance-- maybe even more than men are. Breasts are sexual and sensual, a big part of what makes us women, and they can dictate our sense of attractiveness and desirability (for better or worse). Breast augmentation is one of the top three most popular plastic surgery procedures performed. So many women embrace this procedure because it carries little risk of complication. And because an implant can be inserted through a tiny incision in the navel or armpit (and moved into place under the skin), or under the areola or breast, it's a quick, nearly scarless operation.

A major factor that effects how breast implants look and feel is whether they're inserted over or under the chest (pectoral) muscle. Traditionally I do a submammary implant, inserting the implants under the breast tissue and over the muscle because it's technically a lot easier (displacing the chest muscle requires a little more delicacy). It's also quicker: I insert the implant through an incision in the navel, nipple, breast fold, or armpit, place it over the muscle, and then inflate it when it's snugly in place. The result is fabulous: perkiness with barely a trace of scar.

If you want the most natural-looking breast you'll need a subpectoral implant, in which the implant is placed under the muscle. This procedure also requires the merest incision- about three centimeters in the crease under the breast or at the edge of the nipple-- and diminishes the incidence of capsular contracture, the formation of hard scar tissue around the implant which occurs in 10 to 30 percent of cases.

Subpectoral implants aren't right for everyone, though. If you have saggy breasts, and implant placed under the muscle won't fill out that empty breast sack, and you'll get what we call the "double bubble" look, where the implant is situated next to your armpit and the breast hangs several inches below it. Instead, you can have a procedure called augmentation mastoplexy, in which the implant is placed under the muscle and the skin on the breast is lifted and tightened.

In short, you must know--realistically-- what you are starting with, as well as what you want to look like when surgery is done. Do you care more about the placement of the scar or about a quick painless procedure? Do you want a natural appearance or a round, perky look? These are some of the factors I weigh with my patients when evaluating what type of procedure to do.

Under the muscle is more natural, but size is a more important factor

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The pec muscle looks like a triangle with borders along the sternum and clavicle. When an implant is under the muscle, the muscle helps maintain the slope to the upper portion of the breast. Natural breasts have more of a slope above, and curvature below the nipple. That being said, if you choose large implants (or too large), no matter where you place them, they will look fake. Reasonable sized implants can be make to look natural, and the muscle helps.

Which Position Gives The More Natural Looking Breasts - Under Or Over The Pectoralis Muscle?

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When using round breast implants, under the muscle gives a more natural appearance.  Teardrop implants theoretically look more natural on top the muscle, however since they have a tendency to rotate, I do not recommend teardrop implants. 

The placement of subpectoral implants is done after the pectoralis muscle is cut off its insertion into the fifth rib.  Once this connection of the pectoralis muscle is released, the muscle retracts upward, making a sub-muscular implant actually a partially sub-muscular implant.  When the muscle is released upwards even more, it is referred to as a Dual Plane.

There was a famous plastic surgery meeting in Dallas where a Board Certified plastic surgeon showed a number of round implants in the partially subpectoral space on lateral mammogram, and they were all teardrop due to the muscle pushing on the upper 50-70% of the implant, and the lower portion bulging forward.  Round implants in the partially subpectoral space give the natural teardrop appearance of mature breasts, but have the advantage over teardrop implants,  that no matter how they turn, one will never get a diagonal breast.

Therefore, round implants in the partially subpectoral space give the most natural appearance to the breast.

Over the muscle or under the muscle

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Thanks for the question.  Going over the muscle is not really indicated for every patient.  You must have at least 2 cm of breast tissue at your upper pole to qualify.  This is because if you go over the muscle on a thin breasted woman the outline of the implant will be too noticeable.  Sometimes placing implants over the muscle can help breast that have a little sag to them.  Going over the muscle however has its drawbacks.  It has a much increased rate of capsular contracture.  That is when the scar tissue that forms around the implant begins to stiffen up.  This can be severe enough to cause deformity or pain.  

I typically perform a dual plane which gets the best of both worlds.  The upper portion of the implants are covered by the muscle.  The lower portion is separated slightly to allow greater contact between the implant and the breast tissue itself.  This gets the benefit of a lower rate of capsular contracture and still has the ability to provide some lift to a woman's lower pole.  It is important to be seen by a board certified plastic surgeon to come up with the best analysis and plan for your body.

I hope this helps :) 

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.