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December 14, 2009

Breast Implants: Consideration #6: Position of Implants - Above or Below Muscle





  • Subglandular implant:  The prosthesis is placed under the breast tissue but on top of the pectoralis major muscle.
  • Subpectoral implant (or submuscular implant):  The prosthesis is placed behind the pectoralis major muscle (which is itself behind the breast gland).

Obviously, Holly, you deserve a customized evaluation, and only then can a Board Certified Plastic Surgeon help you make the best decision.  Nevertheless, there are some general advantages and disadvantages of the two options....

Subglandular Implants


  • Technically easier operation for the surgeon
  • Can be placed without general anesthesia (without going totally to sleep)
  • Larger implants can be accomodated
  • Potentially, more cleavage can be created
  • No surgery on the muscle; therefore, less discomfort
  • No surgery on the muscle; therefore, faster recovery time
  • More "lift" effect, so that formal breast up-lift operations can be avoided


  • The "look" tends to be more artificial and less natural
  • More rippling
  • Greater likelihood of capsular contracture
  • More difficult to interpret mammograms

Subpectoral Implants


  • Usually, a more natural breast appearance
  • Less rippling
  • Lower risk of capsular contracture
  • More successful mammogram readings


  • More difficult operation
  • Requires general anesthesia
  • Can not always produce as much cleavage as the patient might desire
  • More discomfort
  • Longer recovery time
  • Among women with large pectoralis majors, muscle contraction can distort the implant

Practically speaking, I try to convince most of my patients here in Ventura, California (>90%) to undergo subpectoral placements.  The unusual exceptions...

  • Extreme fear of general anesthesia
  • Very low pain tolerance
  • Looking for a "fake" look
  • High performance athletes, whose pectoralis major muscles should not be altered
  • Body builders, in whom muscle flexion would distort their breasts during competitions
  • Male-to-female transsexuals, whose large XY pectoralis major muscles would not accomodate a subpectoral implant

I like saline implants above the muscle when the patient...

  • ...already has a fair amount of breast tissue.
    • Saline implants tend to ripple more than silicone.
    • Hence, those implants need some sort of coverage to camouflage that rippling.
    • That coverage can come from the muscle or from breast tissue.
    • If a woman's breasts are already big, but she would like them even bigger, placing implants on top of the muscle is usually OK.
  • ...wants the most natural results when she exercises (nearly) naked(!)
    • The breasts are naturally on top of the muscles.
    • Therefore, if the muscles move, the overlying breasts shouldn't move that much.
    • However, if the implants are beneath the muscles, the breasts might move unnaturally when the muscles contract.
    • Since most women don't exercise naked, this is a minor issue for most patients.
    • Nevertheless, some women do compete in sports in small bikinis, and they are aware of breast distortions with shoulder/chest muscle contractions (such as beach volleyball players, surfers, body builders...see below)
  • ...is a body builder.
    • Body builders have very well developed muscles.
    • Contraction of those big muscles would significantly distort the positions of sub-muscular implants.
    • These women do pose nearly naked (in small bikinis) while flexing their muscles.
    • Even though these women do not have a lot of body fat, implants on top of the muscle are generally better.
    • In competitions, the rippling of the implants looks less bad than implant distortion.
  • ...has droopy breasts and prefers to avoid formal lift-up procedures
    • Implants themselves provide breast rejuvenation.
    • The muscles tend to mute the rejuvenative/lift-up effects of breast augmentations.
    • Even though many women need mastopexies (lift-up surgeries) at the same time as their augmentations, some patients prefer to avoid the additional scars of mastopexies and accept the limitations of implants on top of the muscles.
  • ...is looking for a quicker recovery
    • Most breast implants surgeries do not require a long recovery.
    • However, positioning of the implants below the muscle is more uncomfortable.
    • Staying on top of the muscle is much less painful.

Generally, I use silicone implants when patients choose to have their augmentations on top of the muscle.  Or, better yet, I place implants beneath the muscle in 90% of circumstances...

  • to minimize rippling
  • to reduce excess scar tissue around the implants (known as capsular contracture)



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