When considering breast augmentation, you and your Board-certified plastic surgeon have 4 main decisions to make:
- The size of the breast implant
- The choice of saline vs. silicone breast implants
- Whether to place the implants over vs. under the muscle.
- The location of the incision
We give “7 Tips to Getting Your Breast Implants Size Right” in our e-Book A Girlfriend’s Guide to Breast Augmentation and I have previously blogged about my advice with regard to silicone vs. saline. So, I thought today I would give my opinion about implant position with regards to the pectoralis (chest) muscle.
Shifting To “Over the Muscle”
Growing up in plastic surgery I was always an ” under the muscle ” kind of guy. But in the last five to seven years since the return of silicone implants, I am doing more breast augmentations with the implants placed on top of the muscle. By “on top of the muscle” I mean that the implant is positioned between the chest muscle and the breast tissue itself, which is known as a subglandular placement, versus a submuscular placement, which is when the implant is positioned under the chest muscles.
2 Reasons Why The Muscle Is Important
What determines where we place the implant? Glad you asked. The chest muscle generally serves two purposes with regards to the implant. It provides additional soft tissue coverage, and it can help shape the upper portion of the breasts.
The first is pretty simple. In women with very little of their own breast tissue, we want to place as much tissue as possible over the implant so that it will look as natural as possible, and not like an implant. With women who have little or no breast tissue, it can be quite a challenge to make their breasts not look like an implant – because that is almost all there is. So, if we placed their breast implants on top of the muscles, they would probably look like two round objects, sort of like half coconuts. Certainly not the look most women are going for.
The second purpose of the chest muscle with regards to implants is to get a more natural look of the upper part of the breast. The most natural look of a breast is to have a bit of a slope to the upper portion, and not be overly round. When an implant is placed under the muscle, it puts some pressure on the implant and helps give the sloped look to the upper breast. This is particularly important with saline implants. Saline breast implants are stiffer than silicone implants, and require more pressure on top of them to achieve this natural look. So with saline, I will almost always go under the muscle.
Another Option For Better Shape
I should point out that the other way to achieve this look is to use a shaped or tear drop implant. But I am not a big fan of these for a number of reasons, although we have them available for women who want them. These are making something of a comeback especially with form stable implants (aka gummy bear implants) particularly in post-mastectomy breast reconstruction.
Over The Muscle Advantages
One of the advantages of going on top of the muscle when we can, is that the shape of the breast will not be affected as the chest muscles contract. When the pectoralis muscle is flexed it will press down on the implant and change its shape by either slightly flattening it, or by moving it a little upward or to the side. This is not harmful, and resolves when the muscle is relaxed. But it doesn’t happen if the implant is on top of the muscle. [As a caveat, if I am working with someone who is a very heavy weight lifter, or competing in body building competitions, we will generally go on top of the muscle. Their breast implants may not look quite as natural as I would like, but with very large pectoralis muscles the look will be much more unnatural under the muscle, particularly when they flex.]
Occasionally I have had patients who have elected to have their implants moved from under to on top of the muscle. Some find that in the new position, they feel more comfortable or more natural.
I’ll Recommend “On Top” If…
So, the women I am most likely to recommend going on top of the muscle are generally using silicone breast implants and have a good amount of their own breast tissue, around a B cup or larger. When there is a significant amount of breast tissue, there will be adequate soft tissue coverage making the pectoralis muscle superfluous in this regard. And, silicone implants are softer than saline, not as stiff. So they are more likely to have a natural slope of the upper portion without having the muscle on top of them. Frequently I will go on top of the muscle for a woman who is getting a modest augmentation with a breast lift. If I am doing a breast enlargement on a woman with a full B-cup who is using silicone and not going huge with the implant, over the muscle can work great.
In almost all cases where placement on top of the muscle is considered, the implant can be placed below the muscle as well. But the opposite is not true. The only exception might be in someone who has a bit of sagging but either not enough to warrant a lift, or in a woman who does not want a lift. In this case over the muscle is better as this will allow the implant to follow the natural shape of the breast. In essence, it will “sag” slightly just like the breast. This can tend to give more of a “mature” look which some women are content with. But if there is too much sagging a lift will be needed.
Note: On all of our before and after pictures of breast augmentation patients, we include the implant placement in the description.
3 Common Misconceptions
Let’s address a few misconceptions:
- The muscle will prevent sagging. Breasts sag, implants don’t.
- The muscle will protect the implant and make rupture less likely. Generally not true. Most implants rupture due to fatiguing of the shell of the implant due to time and stress, not to a nudge from an elbow at the dance.
- Implants must be under the muscle in order to have a good mammogram. While there are some radiologists who feel that mammograms are better if the implants are under muscle, an equal number feel that there is no real difference. The more important consideration is the softness of the breast an implant.
So, the bottom line here is that women with more breast tissue who are using silicone may have the options to go on top of the muscle. And they may achieve some of the most natural results. But if they would prefer to have the implants under the muscle, that can work as well.
All the best,
David B. Reath, M.D.
PS: Here’s another link to the eBook my office staff wrote. It’s a free download so you might want to check it out.