Breast augmentation or breast implants is one of the most common procedures performed. I am frequently asked about where is the best place to put an implant. That question is multifactorial and I will discuss them all below. A breast augmentation entails making a small incision and then placing an implant, either silicone or saline, into a pocket that is created to enlarge and modify the breasts.

Breast Implants: Under vs. Over The Muscle – Which is best?

The question of placing an implant above or below the muscle creates more confusion and controversy among both patients and surgeons than most other questions in cosmetic surgery. The first issue is that there is no answer that is uniform for all women. Each person’s own physical characteristics may make the choice for one woman or her surgeon entirely different from another. Another problem is apparent confusion about the medical terminology that applies to this issue.

Subglandular – this means placement of the implant above the pectoral muscles but below the mammary gland. Technically, all implants are subglandular because implants placed below muscle are also below the mammary gland. However, this term refers to placement just below the mammary glands and above the muscle. This placement is also referred to as submammary.

Subfascial – Another option instead of over OR under the muscle is called “subfascial,” which is a sort of compromise between the two. Although it is thin, the fascia is usually substantial enough to provide a layer behind the breast and in front of the implant. The implant goes in front of the muscle but under the COVERING of the muscle, the fascia.

Subpectoral – often referred to as “submuscular,” subpectoral means placement of the implant below the pectoralis major muscle. In subpectoral placement, the implant is only partially submuscular due to the nature of the pectoral muscle under which the implant is placed. The lower half of the implant is not covered by muscle in this type of placement.

Partial Sub-muscular Placement (Also Known as Dual Plan Placement): This placement has many names, but essentially the implant is placed partially below the muscle. This can also be referred to as partial sub muscular or partial subpectoral.

Advantages and Disadvantages

Capsular contracture – Many surgeons believe, based upon clinical studies regarding placement of the implant and contracture rates, that placing the implant below the pectoralis muscle (subpectoral), reduces the rate of capsular contracture when compared to above the muscle placement of the implant. Keep in mind that there is not total agreement as to whether this is truly the case. This reduction in rate for subpectoral vs. subfascial is minor and we have methods to help keep contracture rates low for all implant locations.

Rippling – In women with little breast tissue, subpectoral placement is likely to reduce the chances of visible rippling of the implant. This should be true regardless of the originating reason for the rippling (underfilling or textured surface, depending on the opinion held) because the implant is partially or fully covered by muscle, in addition to breast tissue.

Initially, and especially with silicone implants, implants were predominantly placed above the muscle (subglandular). Most surgeons can agree that in the ideal case where a woman has adequate breast tissue to disguise the implant and assuming no rippling or contracture, above the muscle placement would result in the most likely natural looking result because the implant is behind only the tissue itself, the tissue that is being augmented and which will take on the augmented shape.
In women with adequate or a lot of breast tissue, subfascial (above muscle) placement is likely to yield the most natural looking result. Women who work out with weights complain of an unusual appearance while working out with implants that are behind the muscle. This occurs because as the muscle contracts it distorts the shape of the implants and with time moves the implants laterally toward the armpits. In most women with average to little breast tissue, under the muscle placement can help to avoid the “fake” look of implants that are apparent because they are closer to the surface.

A potentially more natural look for over the muscle placement is mostly true in women with any significant sag or droop (ptosis) of the breast tissue. Because the pectoralis muscle tends not to sag, placement of the implant behind the muscle means that the implant is likely in these women to be higher on the chest than sagging breast tissue, which will tend to look like separate tissue hanging from the firmer, higher mound of the implant – called a “snoop” deformity.

Because of this, in cases where subpectoral placement is desired, many surgeons will recommend a mastopexy (breast lift) in conjunction with a subpectoral augmentation when there is significant droop.

The Decision
The decision to have a breast augmentation and all the decisions going into can be difficult. Dr. Wright will work closely with you to help you decide what implant and size would fit your body type best as well as the best location to place the implant. Dr. Wright’s desire is to help you achieve your goal of how you have always wanted your breasts to look!