Should I Get Over the Muscle or Under the Muscle Breast Implants?

Dr. Robert Schwartz

November 28, 2022

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Should I Get Over the Muscle or Under the Muscle Breast Implants?

If you’ve been researching breast augmentation, you probably know that your plastic surgeon can place your breast implants on top of (subglandular placement) or underneath your pectoralis major chest muscle (submuscular placement). You’re probably also aware there is some debate about which is better and why.

In this post, we will argue that under the muscle implants are always the better choice. (Ok, there’s one potential exception, and we’ll get to that too.)

What Does Putting Breast Implants Under the Muscle Mean?

The muscle involved in breast augmentation is the pectoralis major muscle. It starts at your shoulder and fans out across your chest wall, attaching to your clavicle and your breastbone. It sits right underneath your breast tissue and on top of your smaller chest muscles - the pectoralis minor and the intercostals.

Anatomy of the pectoralis major muscle

A plastic surgeon can position your breast implants four ways in terms of your pectoralis chest muscle.

Subglandular Breast Implant Placement

With subglandular implant placement, the surgeon raises your breast tissue off the underlying pectoral muscle and places the implant directly under the breast. All chest muscles lay beneath the breast implant.

Subfascial Breast Implant Placement

Subfascial implant placement is identical to subglandular placement except that the plastic surgeon lifts both the breast tissue and the top layer of fibrous tissue that covers the pectoralis major (the pectoralis fascia.)

Subpectoral Breast Implant Placement

When a patient or surgeon refers to “under the muscle placement,” this is what they mean. The plastic surgeon raises the breast tissue and the pectoralis major muscle along with it. This allows implant placement under the pectoralis muscle.

Total Submuscular Breast Implant Placement

Because of its anatomy, the pectoralis major only covers about 3/4 of the typical breast implant. The outer edge of the pectoral muscle travels diagonally from the shoulder toward the lower middle chest wall so the bottom outer edges of the breast implants extend past its border. They are covered by breast glandular tissue only.

The entire implant can be covered with muscle by lifting the serratus muscles and the rectus abdominis muscles along with the pectoralis. This technique, called total submuscular placement, creates fully under-the-muscle breast implants.

Where Should I Have my Plastic Surgeon Place my Breast Implants?

Here is our advice for breast augmentation implant placement. We will start with our least recommended implant placement and proceed to our favorite. For each position, we will list the advantages and give our overall assessment. These recommendations are valid regardless of the implant size used. They apply to both larger and smaller breasts and to both silicone gel and saline implants.

Total Submuscular Placement

If it’s best to place implants under the pectoralis muscle (spoiler alert - that’s where we’re heading), isn’t it even better still to place them entirely under muscle? Well, no. The anatomy of the pectoralis major muscle lends itself perfectly to breast augmentation.

  • It can be elevated easily and almost bloodlessly.
  • Raising the pec muscle is not particularly painful postoperatively (if it's done gently.)
  • Lifting the pec major muscle doesn’t weaken it or compromise future physical activity.
  • The pec muscle is big enough a stretch and provides adequate soft tissue coverage over larger implants.

Contrast the serratus muscle. It bleeds quite heavily when dissected off the chest wall. Serratus elevation hurts for several weeks or more. The serratus is thin and flimsy and doesn’t provide much additional coverage to the augmented breast.

The rectus abdominis muscle is easier to elevate in surgery and not particularly painful postoperatively. But lifting the rectus muscle can weaken support for the implants and create an increased risk of bottoming out and double bubble formation.

There is a role for totally submuscular implants, and we do occasionally perform this type of breast augmentation. We find the extra muscular coverage can be helpful in thin patients seeking revision of very large breast implants. Because of the outward pressure from these oversized implants, these women have very little natural breast tissue. Implant rippling (visible folds) will show through their minimal breast tissue.

In these patients, placing implants fully under muscle adds more natural tissue. Though this may produce a more natural breast contour, the plastic surgeon needs to describe thoroughly the potential issues of this approach in a one-on-one consultation.

Subglandular Placement

Advantages of subglandular breast implants include:

Less Pain

The recovery is less painful than with the subpectoral implant position. With modern atraumatic ways of lifting the pec muscle, this difference is minimal.

Less Swelling

Subglandular placement causes less swelling than under the muscle implants. Again, with good plastic surgery technique, the difference is small and temporary.

More Lift

Subglandular breast implants add a little lift to the nipples and can eliminate the need for a mastopexy in women with borderline sagging. True, but the weight of the poorly-supported subglandular implants will cause more sagging over time. Also, the added breast lift effect can be duplicated with dual-plane subpectoral placement technique.

Some plastic surgeons recommend over-the-muscle placement in women who have more breast tissue. They use an upper breast pinch test and place implants subglandularly in women with a pinch greater than two centimeters.

We think the pinch test is unscientific and that all women benefit from subpectoral implant placement. Except for perhaps one group...

Competitive bodybuilders

Breast implants placed over the muscle can animate, meaning that when you flex or contract your pec muscle, the implant moves a little. For most women, the movement is slight, and it’s a minor issue.

But for a bodybuilder, this might be a problem in competition. Also, as bodybuilders weight train, the heavy weights they repetitively lift may shift the implants over time, moving them outward to the sides of the chest from the forceful contraction of the pectoralis major.

We advise our competitive bodybuilder patients to consider putting their breast implants over the muscle, but it’s not a perfect solution. Bodybuilders have minimal body fat and typically very little breast tissue. This can make the edges of a subglandular implant visible. So whether or not to place the implant above or below the muscle must be decided on a case-by-case basis.

Subfascial Placement

Subfascial breast implants are placed between the pectoral muscle and the fascia that covers it. The fascia acts as an additional layer of soft tissue coverage for the implant. The thin fascia may produce a slightly more natural appearance than subglandular breast implants. But the added coverage and support are minimal compared to the benefits of using the larger chest muscles.

This brings us to our top choice for breast implant placement...

Subpectoral Placement

Subpectoral breast implant placement is the gold standard for breast augmentations and is the choice of most board-certified plastic surgeons. Its advantages are compelling.

Natural Look and Feel

Your pec muscle adds another layer of soft padding over the breast implant. This invariably gives you a more natural-looking breast augmentation. It makes it harder to see the edges of the implant. It minimizes implant rippling. It makes the implant difficult to feel. Also, the top and bottom of your breast transition more smoothly off your chest when your breast implant is under the muscle.

Subpectoral implant placement yields more natural breasts regardless of how much breast tissue you start with. But the less breast tissue you have, the more critical the added padding is.

Improved Implant Support and Stability

With your breast implant under the pectoralis, the muscle itself holds the implant in place, providing stable support, and giving breast augmentation patients a much better result over the long term. Because muscle is strong and stable, it holds the implant in position well.

Breast tissue stretches and sags. It can also thin and weaken over time. Placing an implant over the muscle exacerbates stretching and sagging by taking a breast that might naturally sag a little and adding weight to it. The result is completely predictable. You need the pec muscle to lock in the breast implant effectively.

Better Mammograms

Breast implants placed over the muscle prevent good mammograms. Implants under the muscle do have a mild impact, but it’s nothing a trained mammographer can’t compensate for. Studies also show that subpectoral implants do not delay the diagnosis of breast cancer. Subglandular implants (over the muscle) do. This alone is reason enough to avoid putting breast implants over the muscle.

Capsular Contracture Prevention

Capsular contracture is a potential complication of breast augmentation. The scar tissue around the implant hardens and sometimes contracts, causing pain and distorting the implant’s shape. Subpectoral implants are less prone to capsular contracture than subglandular ones. This is most important with silicone implants and smooth implants, as both of these implant types are more susceptible to capsular contracture.

Summary

Overall, there are four basic ways that breast implants can be positioned during breast augmentation surgery. While each method has its own set of benefits and drawbacks, we believe that placing the implant under the pectoralis muscle is the best choice for most patients. This technique results in a natural look and feel, as well as decreased chances of developing capsular contracture. If you’re considering breast augmentation surgery and have questions about which implant position would be right for you, call or text us today – we’d be happy to discuss your options in more detail.

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