Breast Implant Placement: Over vs. Under The Muscle
Originally published on October 24, 2014. Updated April 23, 2021 with additional information
During a breast augmentation procedure, an implant may be placed either over the muscle or under the muscle. Multiple factors play a role in determining the optimal implant placement for each individual patient, including patient health history, implant type, implant size, and the patient’s body type.
If you’re considering breast implants, you may have heard you can choose to place them over or under your chest muscles. Which is better for you depends on several factors, including your age, current breast anatomy, activity level, and tolerance for post-surgery down-time.
While an experienced plastic surgeon is in the best position to determine optimal implant placement, it is vital for breast augmentation patients to understand the benefits and drawbacks to each technique. Learn more about which breast implant placement, over or under the muscle, is best for you.
(Image via Info Plastic Surgery)
Over the Muscle (subglandular) Breast Implant Placement
When a breast implant is placed ‘over the chest muscle’ it’s placed under the breast’s glandular tissue. This method is sometimes referred to as subglandular placement. Because the chest muscles, or pectoral muscles, are not manipulated in this procedure, recovery tends to be quicker and less painful.
You might choose over the muscle breast implant placement if you already have ample breast tissue and you’re looking for a moderate, natural-looking enhancement. Your natural glandular tissue will cover the breast implant, which minimizes the risk of implant visibility, rippling, wrinkling or folding.
If you lift weights, or participate in activities which strengthen your chest muscles, over the muscle implants are at less risk of distorting as your pectoralis muscles develop.
Pros of Over the Muscle Placement
Potentially quicker, less painful recovery
Surgical procedure is much easier and less invasive compared to under the muscle placement. Because your pectoral muscles stay intact during this procedure, your body will heal sooner, typically with less discomfort.
Larger implants are possible
When implants are placed over the muscle, there’s no limit to the size of the breast implant pocket that can be created. This means larger sized implants may be used. This method is thus preferred for those already at least a B cup who are seeking dramatic change.
Avoids dynamic distortion
Dynamic distortion is the lateral breast movement that occurs in some implants when the chest muscles are flexed. This type of movement will not occur when implants are placed over the muscle.
Generally, more cleavage can be created because the implants can be placed slightly closer together.
Can lift slightly sagging breasts
Placing a shaped implant over the muscle is a potential alternative to a breast lift.
Natural looking results that age with you
That said, an implant placed over the muscle will subtly descend as your breasts descend with age. This helps maintain a natural look as you get older.
Cons of Over the Muscle Placement
The risk of visibility is greater when the breast implant is placed over the muscle. This is especially true for those with minimal natural breast tissue, or very low body weight. This can also include a more dramatic or visible “step-off’ at the upper pole of the implant since the muscle does not smooth the transition.
Rippling, wrinkling and folding
Increased risk of visibility also means increased risk of seeing rippling, wrinkling, or folding, especially near the top of the implant where natural tissue is thinnest.
Capsular contracture is an immune system response in which the body reacts to the implant as a foreign object and surrounds it with scar tissue to isolate it from the rest of the body. It’s not known why some develop this condition and others don’t, but it’s more common in over the muscle implants.
Bottoming out is a rare phenomenon in which the implant drops too low on the chest wall. This happens when skin elasticity is insufficient, or if the implant wasn’t properly placed during surgery. It’s far more likely to occur with implants placed over the muscle.
While it’s possible to have a safe and effective mammogram after any type of breast implant surgery, over the muscle placement can interfere with breast tissue visibility.
Under the Muscle (submuscular) Breast Implant Placement
Placing a breast implant ‘under the muscle’ refers to submuscular placement in which the implant is placed below the pectoralis muscle. During implant insertion, the pectoralis muscles are split. This makes the breast augmentation recovery experience longer and possibly more painful.
The under the muscle method is recommended for those with little natural breast tissue, as the muscle covers the implant, creating a more natural-looking result. If your natural breasts have already sagged due to age, an under the muscle implant can look unnaturally high, in which case over the muscle placement is preferred or a breast lift (mastopexy) may be added.
Saline implants are typically placed under the muscle because they are firmer than silicone implants. The muscle wall offers protection from puncture and also reduces implant visibility.
Pros of Under the Muscle Placement
Natural looking results
Because the pectoralis muscle covers the implant, this method is preferred for women with little natural breast tissue or for those who are very thin. The muscle effectively pads the implant for a more natural-looking result. This creates a more smooth upper pole and reduces the “step-off” that is possible (especially with higher profile implants)
Reduced risk of capsular contracture
Under the muscle implants reduce the risk of capsular contracture from nearly 18% to less than 10% in primary augmentation patients.
Reduced risk of visibility
Due to reduced implant visibility, there’s less risk of visible rippling, wrinkling, or folding when implants are placed under the muscle.
More visible mammograms
Although it’s perfectly ok to get a mammogram with any type of implant, under the muscle placement leads to less distortion and a more easily readable mammogram.
Cons of Under the Muscle Placement
Under the muscle breast implant placement requires a longer recovery period. Your breasts may also be more painful in the first few days following surgery.
Lateral breast movement occurs more frequently when implants are under the muscle. With dynamic distortion, breast implants move sideways as the pectoral muscle contracts. Implants may also become displaced if extreme changes to musculature create pressure on the implant.
Snoopy Deformity describe a situation wherein the breast tissue sags below the breast implant. The muscle holds the implant in place while the breast can continue to sag due to lax tissues or aging. This does not typically occur with subglandular placement because the implant sags WITH the breast. The treatment for snoopy deformity is typically a breast lift (mastopexy).
Double bubble deformity
Double bubble deformity can occur in either subglandular or submuscular implant placement. This typically occurs when the breast implant pushes through the natural inframammary crease of the breast causing a new crease below the natural one. This can occur with settling of the implant or from surgical lowering of the fold to accommodate the implant selected by the patient and surgeon. Double bubble deformity can be treated by surgically restoring the natural fold adherence to the chest wall (capsulorrhaphy) or by fat grafting procedures if the new fold position is necessary for the selected implant size.
Which Breast Implant Placement is Best for Me?
Over the Muscle Breast Implants
You are more likely to choose over the muscle breast implant placement if any of the following is true:
- You are already a B cup or larger
- If you are seeking more dramatic change (choosing large implants)
- You are active and exercise your chest muscles consistently
- You have no family history of breast cancer
Under the Muscle Breast Implants
You’re more likely to choose under the muscle implants if one or more of the following is true:
- You wish to minimize the risk of capsular contracture, visible rippling, or visible step-off at the upper pole of the breast implant
- You have minimal natural breast tissue
- You’d prefer saline implants
- You aren’t seriously involved in strength training
- Clear, easily readable mammograms are important to you
Video Explanation: Over vs. Under Muscle Implant Placement
Of course, every situation is unique. To make the most informed decision on which breast implant placement is best for you, consult with your doctor.
Given this, the women I am most likely to recommend over the muscle placement are generally those opting for silicone breast implants and have a good amount of their own breast tissue, and in those patients with very large or strong chest muscles (ie body builders). When there is a significant amount of breast tissue, there will be adequate soft tissue coverage making the pectoralis muscle superfluous in this regard. Also, those with robust chest muscles are more likely to have significant distortion on animation and should consider subglandular placement. Silicone implants are preferred for subglandular placement due to their more natural look and feel compared to saline implants.
In most cases, I recommend submuscular or “dual plane” placement with silicone implants. This gives a natural, long lasting result for most patients and yields the lowest complication rate. Further, it facilitates future breast lifting procedures by preserving the best blood flow to the nipple.
Additional Resources On Implant Placement
- RealSelf.com Implant Placement Questions Thread
- Mayo Clinic
- American Society of Plastic Surgeons
- American Board of Cosmetic Surgery
- Consumer Guide to Plastic Surgery