Why are some breast augmentations performed over the muscle?

A friend of mine had breast augmentation last winter and mentioned that her implant was put under the muscle.  I went for a consultation 2.5 weeks ago and the doctor mentioned he does a lot of his breast augmentations above the muscle and believes it yields better results.  From what I know (which is not a ton), it seems that putting the implant below the muscle is the best way to do it.  Can someone please help!?  Thanks!


F, 32, Minnesota

There's no "better" choice between the two techniques, as the decision between submuscular implants and subglandular implants depends on patient specifics and the individual goals of each patient.

Submuscular placement is the more popular of the two cosmetic surgery techniques, and in my experience tends to yield more natural looking results. For women with small breasts in particular, a submuscular implant is often the superior choice because it requires very little breast tissue. The muscle itself supplies additional soft tissue and naturally contours the breast.


Breast implant placement beneath the pectoral muscle is also statistically shown to have a lower chance of capsular contracture, which is one of the most common complications following breast enlargement. Aside from the natural look and lower capsular contracture rate, in my experience I’ve found submuscular implants generally tend to last longer and look better over the long term. On the downside, when placing implants beneath the muscle the surgery is slightly more complicated while the recovery time can be longer and more painful.

Over the muscle implants tend to have a shorter and less painful post-op recovery, but run the risk of looking slightly less natural if there isn't enough natural breast tissue to provide a natural breast slope. The issue of your natural breast size is important in this consideration: Patients with adequate breast tissue coverage can often achieve extremely natural looking results with over the muscle implants.

Another consideration has to do with very athletic women: Submuscular implants can result in a small amount of muscle weakness and what's called an "animation deformity" in breast augmentation patients with a larger amount of chest muscle.

Lastly, subglandular placements can sometimes make mammograms more difficult. Radiologists tend to have a much easier time with submuscular placements as they don't interfere with the imaging of the mammary gland.

Part of the decision between choosing over the muscle and under the muscle breast implant procedures depends on your choice of implant type:

Silicone implants tend to have a softer, more natural feel than saline implants when inserted over the muscle. Also, because saline implants have a slightly increased risk of rippling and capsule contracture than silicone implants, in most cases I would advise that they be inserted under the muscle.

There are many additional options surrounding breast augmentation which can affect the submuscular/subglandular decision. These include textured implants, shaped silicone gel/teardrop implants and the choice between low and high profile. I would suggest you schedule a consultation with a qualified plastic surgeon to review the full range of options available and see which choices make the most sense for you specifically.

For safety and best results always remember to only consult with board-certified plastic surgeons.

Dr. Christine Blaine has 1 Breast augmentation before & after:

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Different surgeons will have different opinions. The general consensus is that below the muscle will have a higher longevity with less risk of Capsularcontracture or implant malposition. You can get nice results above the muscle but they are more prone to those issues. The main patient population that I would use the implants above the muscle is bodybuilders. Any implant below the muscle will have an animation deformity. This means that when you flex your Pectoralis muscles, the shape of the implant will be distorted. Bodybuilders have to flex on stage and so it's better to avoid that. I also will remain above the muscle if a patient has had above the muscle implants before and is happy with them but simply trying to change size etc. If a patient has enough droop that a lift is recommended but the patient refuses to have the lift, an above the muscle implant allowed to drop down in the skin pocket can be appropriate. But this will over time continue to descend

Dr. Christopher Park has 3 Breast augmentation before & afters:

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The majority of breast augmentations are either sub muscular or now 'dual plane (partially under fascia of the muscle). Over the muscle placement has very strict criteria today. Best to seek a few in person evaluations with only boarded PSs. 

The choice depends on the anatomy of the patient, choice of implant size / shape / type, and the expectations.  There is no "better" way.  In our practice we perform both under and over muscle implants, and we customize the operation to the anatomy of the patient.  A one-size-fits-all answer is unfortunately not the correct approach to this operation.

Breast augmentation can be performed either above above or below the chest muscle. Most surgeons use the below the muscle technique. At our center I generally position the implants below the muscle which gives a more natural and softer result. It may also decrease the possibility of capsule formation( hardening). However, if a patient has a moderate amount of breast tissue to start with, I may place the implant below the muscle. 

Thank you for the question. The placement of the implant depends on how much breast tissue a woman has, and the lifestyle she leads. So if you have enough breast thickness to cover the top part of the implant then you are a good candidate for above muscle placement. The recovery is generally less painful and quicker  

Some people prefer above the muscle because they don't want their muscle cut and weakened or if they don't want the animation deformity which happens with under the muscle placement  

Look up some videos of animation deformity and check out this link for an in depth explanation of the difference 


Good luck with your decision!

Dr  Khuthaila 

Dr. Dana Khuthaila has 4 Breast augmentation, Breast lift before & afters:

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Both approaches are acceptable.  Both approaches have advantages and disadvantages.  The subglandular (above the muscle) approach was very popular in the 70-80's.  

Most cosmetic surgeons now recommend placing the implants  submuscular (under the muscle).

1]  Submuscluar implants have less incidence of capsular contraction; but more post surgery pain from muscle spasm due to increase tissue dissection to create the implant pocket.  

2]  Submuscluar implants have a natural look.  The muscle cover allows a smooth transition from upper chest to breast.  The subglandlar implants can give a operated look.  If subglandular implants are placed in thin patients, the implants look like "bumps on a log".  

3] Subglandular implants are slightly easier for the surgeon to place with limited dissection.  There is a greater chance of implant movement due to gravity pull over time.   Submusular implants are a little more difficult  for the surgeon to place with increased tissue dissection; but tend to hold the implant position over time.  

4]  Submuscular implants allow the muscle to displace all the breast tissue forward,  this is important during mammogram examinations in the future.  The subglandular breast implants can cover up or obscure breast tissue on mammograms.   Cancers have been missed due to cover by subglandular breast implants.

5]  Subglandular implants are most requested in muscular athletic body builder patients.  Placing an implant behind the pec muscles would cause breast implant movement and distortion with any muscle contraction.  Imaging the Rock with submuscular implants.  Talk about movement.  

6]  Subglandular implants can be instrumentation to allow fuller shape in patients with constricted breasts or tuberous deformity of the breast. 

Ultimately; do your homework.  Seek an experienced Cosmetic Surgeon who will spend time educating you in regard to your options based on your anatomy and desires.  

Dr. James White has 2 Breast augmentation (Silicone breast implants) before & afters:

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the pendulum has swung back and forth on preferences for implant placement.  With the availability of new implants, sub-glandular (above muscle) augmentation is gaining in popularity.  There are advantages and disadvantages of each option.  Mammography is easier with submuscular implant placement.  On the other hand,  placing an implant beneath the muscle may result in 'dynamic distortion' of the breast - a momentary distortion of the breast associated with movement or tightening of the chest wall muscles.  This doesn't happen when the implant is above the muscle.

Check with your doctor or consult with several to explore which option would be best for your particular anatomy.

There is much debate over the optimal location for the implants in regard to the pectoralis muscle. 

Most plastic surgeons recommend placing the implants UNDER the muscle for the following reasons

1) Less incidence of capsular contracture 

2) More natural look with a better transition from upper chest to breast. Less "fake" augmented look. Many people equate implants on top of the muscle has the Pam Anderson fake look.

3) Radiologists prefer visualizing the breast tissue with the implant behind the muscle.

However, there are some patients who are better suited for placement in FRONT of the muscle. These include but are not limited to very muscular and body builder type patients. For them the animation of their breasts with implants under the muscle would not be acceptable. The other category of patients are women who have constricted breasts or tuberous deformities. These patients need to have the breast tissue radially scored and recontoured to achieve a more aesthetic shape. Why are some breast augmentations performed over the muscle, submitted image.Why are some breast augmentations performed over the muscle, submitted image.

Dr. R. Brannon Claytor has 4 Breast augmentation (Silicone breast implants) before & afters:

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Placing implants over the muscle can provide for a very nice result in the short term.  Over time (months to a few years), though, the appearance of implants placed over the muscle tends to deteriorate.  It is also technically easier to place the implants over the muscle, and it has a less painful recovery than when placed under the muscle.  

Placing implants under the muscle significantly decreases the risk of something called a capsular contracture, which is where the scar capsule that forms around the implant distorts the breast and may cause pain.  It also decreases the risk of palpable and visible rippling, which is where you can feel or see the folds of the implant.  Lastly, placing implants under the muscle tends to give a more natural appearance that lasts longer.  For all those reasons, with very few exceptions I always place implants under the muscle.

Dr. Gary Breslow has 32 Breast augmentation, Breast lift before & afters:

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