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Breast Implants: Over or Under the Muscle?

Breast Implant Placement
The best implant surgery for you depends on a number of factors—including your current breast size.

One of the most common questions women have, when they come to see me about breast augmentation, is: “Should I have my breast implants placed over or under the muscle?” I think most women feel that there is one “right” answer, and usually they think the implant should be under the muscle (this is usually a result of having done some research on the Internet and speaking with friends beforehand).

I love that women are getting involved in the decisions about their bodies; this is important, but as I say to every patient: keep an open mind about what’s best for you until I examine you and understand your goals.

But know this: under the muscle placement is not the necessarily the best for each and every woman.

There are many factors I take into account when making a decision for my patients: implant type (saline or silicone), implant shape (round or tear drop), implant size, and the patient’s body type, especially how much breast tissue she has to cover the implant.

Breast augmentation is an incredibly individualized surgery. This is why I spend a great deal of time with each patient pre-surgery explaining the best implant, the best size, and the best implant position: over or under the muscle.

What’s important to know: there are pros and cons to both over the muscle breast implants and under the muscle implants.

Illustration of under and over muscle breast implants

UNDER THE MUSCLE IMPLANTS: PROS & CONS

Surgeons began placing breast implants under the chest or pectoral muscle (also called submuscular or dual-plane implants) when it was discovered that doing so helped to reduce the rate of capsular contracture—particularly when smooth implants are used.

Capsular contracture occurs when the capsule tissue surrounding the breast implant becomes slightly firm or very firm. The breast can look unnatural and feel painful. For this reason, many women believe that under the muscle implants are best. But there’s more to placement of breast implants than just that.

PROS:

The other benefits of under the muscle implants include:

√ It offers a more natural breast contour, particularly in extremely thin patients (who don’t have a lot of breast tissue or fat). This is true for both silicone filled and saline filled implants but is particularly important when saline implants are used.

Saline implants are filled with sterile saltwater or saline, similar to a fluid that naturally exists in the body. When placed under the muscle, a saline implant—which is stiffer than a silicone implant—requires a bit of pressure (provided by the muscle covering it) to prevent it from being overly rounded and unnatural looking in the top half of the breast.

In addition, smooth surface saline implants are prone to capsular contracture in the over the muscle pocket. Textured surface saline implants may reduce the risk of capsular contracture, but textured round saline implants have a fairly high rate of deflation.

Today most women choose silicone implants but if a woman has thin breast tissue, most silicone implants will need to be placed under the muscle. In women with borderline thin breast tissue, a shaped silicone implant may be able to be placed over the muscle. But women with adequate tissue thickness can have the implant placed either under or over the muscle.

√ There is a reduced risk of rippling—folds or wrinkles in the implant that are visible through the skin (and necessitating an implant revision). Breast implant rippling typically occurs when there is not enough natural breast tissue covering an implant, which is the case if a patient is extremely thin and/or has very small breasts.

√ More breast tissue can be visualized on a mammogram. However, it is medically safe to place implants both under and over the muscle.

 CONS:

The risks/concerns of under the muscle placement include:

√ Over time the implant can become displaced because of the constant force of the muscle on the implant. This is especially true with smooth walled implants.

√ Implants can become distorted or flattened when the chest muscles flex. This is one reason under the muscle implants are not recommended for bodybuilders or women who are serious about lifting weights.

√ There is more discomfort during recovery, but this is a short term issue that can easily be managed by taking a muscle relaxant medication.

OVER THE MUSCLE IMPLANTS: PROS & CONS

When I place the implant over the muscle implant (also known as subglandular or subfascial implants), I’m placing the implant above the pectoral muscle and below the breast tissue.

PROS:

The benefits of over the muscle implants include:

√ Implants don’t flatten out and move laterally when the chest muscles are flexed. We call this movement and distortion “dynamic distortion” and it is not seen when the implant is over the muscle.

√ The implant will “lift” the breast in patients whose natural breasts are sagging a bit. By placing an implant over the muscle, we can possibly avoid a future breast lift, particularly if a shaped implant is used.

√ As the breasts age and naturally descend downward, the implant descends with them—making the breast implants look natural for years to come.

√ The subfascial pocket, as opposed to subglandular, can blunt the implant edge. This creates a natural-looking contour to the breast.

√ Recovery is quicker and less uncomfortable. However, this is a short-term benefit. Any decision about implant placement is based on long-term results and avoiding complications.

CONS:

The risks/concerns of over the muscle implants include:

√ It can increase the risk of rippling in patients with thin breast tissue. If there isn’t enough natural breast tissue to cover the implant, there’s an increased risk of these visible folds or wrinkles developing.

√ There’s a higher risk of capsular contracture, particularly if smooth surface implant is used.

√ Less breast tissue can be visualized on mammography. But, as I mentioned, it is medically safe to place implants both under and over the muscle.

As you can see, there’s no hard-and-fast rule for determining where your implants should be placed. It’s a decision that I make based on each individual patient. When possible, I recommend a shaped silicone implant over the muscle as this gives a very pretty result with a quick recovery. With enough tissue coverage, the implant looks incredibly natural. Because all shaped implants are textured, and texture helps prevent capsular contracture, this is a good option in the over the muscle position.

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