David B. Reath, MD
Knoxville, TN (865) 450-9253

Best Breast Implant Placement: Over vs. Under the Muscle

Over the Muscle or Under the MuscleWhen considering breast augmentation, you and your Board-certified plastic surgeon have 4 main decisions to make:

  1. The size of the breast implant
  2. The choice of saline vs. silicone breast implants
  3. Whether to place the implants over vs. under the muscle.
  4. 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,

Dr. David B. Reath

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.

 

A Girlfriend's Guide
to Breast Augmentation
Download E-Book Now

97 Responses to Best Breast Implant Placement: Over vs. Under the Muscle

  • cyndi fraser says:

    OMG thanks for this info. So helpful, I want over the muscle with silicone, I am a personal trainer and do a lot of push up ect and my Dr suggested over and everyone is telling me under! I am C cup now and would like to be a DD….Nervous

  • David B. Reath, MD says:

    Cyndi,
    Thanks for your comment. I think that you will probably be better off with implants on top of the muscle, especially if you are already a C cup. But a word of caution about going too large; you don’t want them to get in the way!
    All the best.

  • Sarah says:

    I’m a small b cup and a pretty small person in general, I’d like to be at least a full c. After reading your very helpful artical I was thinking over the muscle with the silicone…my only hesitation, am I to small for the over the muscle procedure?
    P.S.
    Do you have any recommendations of good surgeons in the south Florida area? 🙂

  • David B. Reath, MD says:

    Sarah,
    Thanks for your comment. Without seeing you, it will be difficult for me to know which position for the implants would be better. It’s really an interplay between the amount of breast tissue you have and the size of the breast implants you are going use.
    Florida has tons of very good plastic surgeons. Some that I know personally are Stephan Baker, Onelio Garcia, and Roxanne Guy.
    But you can go the plasticsurgery.org and use the find a surgeon tool to find one near you.
    All the best,
    David B.

  • Anna says:

    I have saline now on top of muscle, one breast starting to look bad. Will probably need another operation, breast are really round and not natural looking. Thought about going under the muscle, maybe using silicone, am a B but thought going full C. What do you think would make them more natural and would going little bigger look ok

  • David B. Reath, MD says:

    Anna,
    Thanks for your comment/question. While I cannot say for certain what might be best for you without seeing you, I suspect that you will do much better with your implants under the muscle and switching to silicone. This should help with the shape and the look of your breasts.
    All the best,
    David B

  • Brittney says:

    after reading your article it gives me a little more peace of mind about going over the muscle. I want a very round shape and I am a C cup now. I am using silicone without a doubt. However, I have been on a couple of consultations and the last Dr I saw has me almost scared out of going on top of the muscle. I have the tissue etc for over but he said if and when I need them redone in the future it will be a hard painful surgery and he said there are more risks for over?

  • Autumn says:

    I am a size 12 with broad shoulders and very tiny A/B breasts. I have nursed 2 children so what little I have, looks rough. I want to get implants but I’m not sure if we are done having children, does over vs. under affect the ability to nurse? Also, I am interested in going up to a full C but my husband thinks I could pull off a D, would size affect ease of nursing?

  • David B. Reath, MD says:

    Autumn,
    Thanks for your comment/questions. Going over vs under the muscle does not really affect the ability to breast feed, nor does the size of the implant you use. But if you are fairly small right now, it is likely that you will be best going under the muscle.
    All the best,
    David B.

  • David B. Reath, MD says:

    Dear Brittney,
    For the right people, I think that going over the muscle has the same risks as going under the muscle. And I do not agree that revising someone with implants over the muscle is more painful that if you revise someone under the muscle. The real issue is whether you have enough breast tissue to go on top of the muscle. And if you are truly a C cup, you probably have enough of your own breast tissue.
    All the best,
    David B.

  • Rae says:

    I was a D cup but after babies I was VERY saggy. I got 455cc cohesive silicone under the muscle. I did under because I was told it was the best way to go to prevent sagging by 2 surgeons. I ended up having one more baby (my last!) and now they are a hot mess. I should have had a lift originally but elected not to because I didn’t want the scaring. Now I’m not sure what to do. I definitely want a lift but what would moving my implants from under to over entail? Would it be a lot mor recovery time? And do you have any recommended surgeons in Colorado?

  • David B. Reath, MD says:

    Rae,
    It sounds like you may have needed a lift before your last child, but you probably really need one now. Whether or not something needs to be done with your implants is something that you will need to discuss with your surgeon. But the recovery should not be too bad.
    To find a surgeon near you I would go to the Find a Surgeon link on the website of the American Society of Plastic Surgeons at: http://www1.plasticsurgery.org/find_a_surgeon/
    This should point you in the right direction.
    All the best,
    David B.

  • Cat Robinson says:

    Hello,
    I am from the UK and have my surgery booked for Friday. I originally wanted under the muscle but my surgeon is suggesting overs. I have hardly any breast tissue and looking through your case photos, all the cases you have done as ‘under the muscle’ are around the same size as mine, some even have more tissue than me. I am having silicone implants 265CC. Is my surgeon just looking for an easier job by convincing me to have overs?

  • Kerri says:

    Hi Dr Reath
    Great article! I’m in Australia and the two surgeons I have consulted have both recommended over the muscle placement without telling me why. I can only assume its because I have strong pectoral muscles (I’m a kickboxer).

    I am worried about the higher capsular contracture rates. How do you usually prevent this?

    I’m an A cup and I want to be a C cup. Despite only being a US size 4, I’m quite hourglass through having broad shoulders and back. I’ve been recommended to get a 350cc – 435cc high profile silicon round implant over the muscle. Without seeing my current shape, what are your thoughts on this? I would have thought this size implant was too big…

  • Dr. Reath says:

    Cat,
    Several things:
    1. I cannot comment definitively on you without seeing you, that said,
    2. It is actually easier to place implants under the muscle than over the muscle as long as the patient is under general anesthesia.
    3. It does sound like, from your description, that you would be better off with implants placed under the muscle.
    4. If you are not happy with the plan that your your surgeon is proposing, don’t have surgery! At least not yet. Either work with your surgeon to get a plan you are happy with, or seek a consultation with another surgeon.
    All the best,
    David B. Reath, MD

  • Dr. Reath says:

    Kerri,
    As you alluded to, without seeing you I cannot comment on what might be best. But if you have very large pectoralis muscles and you work out a lot with your chest, it may be a better option to go over the muscle. There are advantages and disadvantages to both positions. In terms of prevention of capsular contracture I would be very aggressive with massage.
    But if you are uncertain as to why your plastic surgeons have recommended going on top of the muscles, ask them why they want to do this.
    I would also think that you definitely should go with silicone, and I would use the smallest size that you would be happy with as the implant may be a bit more obvious on top of the muscle.
    All the best,
    David B. Reath, MD

  • Krikytt says:

    Dear Dr. Reath,

    Salutations! I’m a current full(ish)38C and have been considering augmentation for a while. I properly fill the cup of 38C, but wear a 40D for the extra bust space, but have extra room in the cups. I want to do silicone under the muscle to help with the “natural slope” look, and am considering the tear drop shaped implants, but also would like it done through my areola for lack of scar marks. I also am slightly smaller on the left side. I know I should have a lift, but due to apprehension of visible scar marks, I’d like to know if I got the implants large enough, would they help lift on their own? If I remember my consult correctly, the size I wanted to have was 380 or so ( I want to be a full DD). Also, due to wanting to even out the lesser left side, is silicone even an option for me, or would saline fix that better? The surgeon I spoke to said he would reduce some tissue on the right side to balance them out, and then place the implants. What are your thoughts on the matter?

    Respectfully,
    K.H.

  • David B. Reath, MD says:

    Dear KH,
    Thanks for your comments and questions. Let me begin by saying that I cannot give you specific recommendations without seeing you. However, some generalities.
    If you need a lift, you need a lift. Going with a bigger implant to try and avoid a lift generally means that you will have larger sagging breasts rather than sagging breasts.
    I think silicone implants are superior to saline in almost all circumstances. Usually the difference in size can be compensated for with differing sized implants. However, I am not a fan of the tear drop shaped implants. The are more expensive and don’t necessarily add a great deal. Also, it will be very difficult to place them through a peri-areolar incision.
    Lastly, if you have had a consultation with a plastic surgeon, you should discuss your concerns with him or her.
    All the best,
    David B.

  • Lindsey says:

    Hi Dr 🙂 I’m torn between above or below. My doc will be using gummy bear implants. I do have lots of breast tissue, but very different sizes. I’m a D and a C. I also have 2 kids and lost a significant amount of weight (114lbs) so my breasts are very saggy with lots of loose skin. Is it best to go above the muscle to fill up the skin? What would you recommend?

  • David B. Reath, MD says:

    Dear Lindsey,
    Thanks for your comment and question. Without seeing you, I cannot comment on what would be best for you. There can be advantages to either approach. This is something that I would discuss with the plastic surgeon who is going to be doing your surgery.
    I wish you all the best,
    David B.

  • Maria says:

    Hi Dr.Reath! This article helped me a lot. So I’m pretty sure I want to get 425cc silicone over the muscle high profile I am 13cm. I’m still undecided if I should get textured round silicone. My surgeon recommended it because i do a lot of lifting at work. What would you suggest?

  • David B. Reath, MD says:

    Dear Maria,
    I am glad this blog was helpful to you. Without seeing and consulting with you, I am unable to give you specific advice. That said, my preference for breast augmentation is to use round smooth implants. But what type of implant you should use is something that you should discuss with your plastic surgeon.
    All the best,
    David B.

  • Ashley says:

    Hello Dr. Reath! I found your article very helpful. I currently wear a 34 B and I would like to get modest implants to become a full 34 C or small D cup. I am very active so I am concerned about he movement of the implant when the muscle contracts. I want to get my implants over the muscle but I have read that there is a higher risk of capsular contracture is higher with over the muscle implants. I was just wondering if this is true in your experience? Also, do I have to get teardrop implants or can they still look natural with a round, over the muscl implant? Thank you.

  • Vanessa says:

    Hi Dr. Reath, for someone that is a size A is it better to get implants over or under the muscle for a more natural look? I’m currently a 34A and can’t decide which way to go. Thanks

  • David B. Reath, MD says:

    Ashley,
    Thanks for your comments. You probably would be a good candidate for implants on top of the muscle, but I would need to see you to know for certain.
    There may be a slight increase with capsular contracture on top of the muscle, but I have not had a lot of issues with this. And you can probably get a very natural look with a round silicone implant as long as you do not go too big.
    All the best,

    David B.

  • David B. Reath, MD says:

    Vanessa,
    Thanks for your question. Most women who start out with an A cup are going to have a better result going under the muscle with the implants.
    All the best,
    David B.

  • Jen says:

    Hi Dr. B,

    I am a 34D. I’m happy with my breast size, but I’ve always liked the shape/look of implants. Is it possible to use breast augmentation to achieve this look without increasing the size? Also, if implants are put under the muscle, will they help reduce sagging – or do you absolutely have to have a breast lift to get rid of that? (I’m afraid of the scarring from a breast lift). Thanks!

  • David B. Reath, MD says:

    Jen,
    Thanks for your comment. If you have implants placed you will definitely increase the size of your breasts. Placing the implants under the muscle will not necessarily reduce the risk of sagging. And if you have some sagging, the only way to achieve a better shape is with a breast lift. Otherwise you’ll have bigger breasts that sag.
    All the best,
    David B. Reath, MD

  • Ann says:

    Is there a way to put only part of the implant under the muscle? I have very small breasts and one is even slightly bigger than the other so I really don’t know what to do.

  • David B. Reath, MD says:

    Ann,
    Thanks for your question. In terms of evening out your breast size, using a different sized implant would probably be the best. When implants are placed beneath the muscle the lower, outer part of the implant is not covered by the muscle because of the muscle anatomy. So, when we speak of a sub-muscular placement, we should probably use the term partial sub-muscular placement.
    All the best,
    David B.

  • Maria Cruz says:

    I have a question dr, if placed over muscle and the implants are too high, will there be any chance they come down? I recently had a ba and am considering a revision. The silicone implant was placed over muscle, i went from a b to a c, the issue was my nipples are facing down. I was given a bandeu to wear and was told in time the implants will drop but im very scared that it wont.thak you in advance for any input.

  • Stephanie says:

    I got a boob job two years ago. I went under the muscle which saline. I was a b cup now a d cup. But my right breast every time I make a muscle is seriously deformed what do you recommend. Should I have them redone and go over the muscle with Silicone?

  • David B. Reath, MD says:

    Maria,
    Thanks for your comment. Frequently implants will descend after surgery. The longer you are out from the operation, the less likely this is however. But I have seen changes for up to a year after surgery in some cases. And, it is always easier to deal with implants that are too high rather than too low.
    All the best,
    David B.

  • David B. Reath, MD says:

    Stephanie,
    Thanks for your comment and question. Without seeing you I cannot comment on what may be best for you. However, switching to a silicone implant on top of the muscle should improve the animation distortion that you are seeing. You just need to make sure that you have enough of your own natural breast tissue to allow this.
    All the best,
    David B.

  • jessica says:

    I had a breast reduction about 11 years ago. I am still a D size but not happy with the way the look. My nipples are kinda high and there is some sagging. So I am looking into have implants but have trouble deciding over or under the breast muscle.

  • David B. Reath, MD says:

    Jessica,
    Thanks for your comment. Without seeing you I cannot comment on what might be best for you. However, I have done breast implants in women who have had a breast reduction in the past and are now smaller than they want to be. Most of these women have elected to have the implants on top of the muscle.
    Hope this helps,
    David B.

  • dolly says:

    I just got a masectomy, recommendation was under the muscle implant as over the muscle would be supported by skin tissue only. How do you recommend over the muscle for implants with a masectomy?

  • David B. Reath, MD says:

    Dolly,
    Thanks for your email. Breast implants used for reconstruction after mastectomy should always be placed under the muscle.
    Sincerely yours,
    David B. Reath, MD

  • Amanda says:

    Dr. R-

    I am now a size 34b, after breastfeeding 2 babies over 12 months, they just now longer have any form/tissue there now. It’s basically like loose skin! I have seen a surgeon whom I love, but has recommended me doing over the muscle full c/small d silicone gel, as I am pretty active and do lift weights a lot in the gym, as well as run on the weekends. I am nervous about subglandular implants because
    a) Will the tend to sag more in the long term because they aren’t under the muscle?
    b) Will I have a higher chance of capsular contracture?
    c) Will they still look natural?

    Thanks!

  • David B. Reath, MD says:

    Amanda,
    Thanks for your comments/questions. It is impossible for me to answer you questions with any degree of certainty without seeing you. Generally speaking, however, the less breast tissue you have, the better you are going under the muscle. There is a possibility of a slightly higher capsular contracture rate going on top of the muscle. The best thing for you to do is to discuss your concerns with your surgeon.
    I wish you all the best,
    David B.

  • Carly says:

    I had a breast augmentation 3years ago . I was a small B . My surgeon recommended on top of the muscle . I loved my breast at first but now I feel one of my breast is settling differently . Within the last year i have started to lift weights and my body fat is decreasing. I fear i may have to have another surgery . But i am not sure if i should stay with over or under. Any thoughts ? Do you have any recommendations for surgeons in NC or VA? Will going under the muscle help with sagging over time ? Thank you

  • michelle says:

    Thank u sooo much, your information Doc B it has been so helpful and has answered most of my questions, pity u are not in the UK i could have made my consultation appointment immediately with u ,but i will be browsing online via the links u have mentioned in order to arrange my breast replacement as i have had these in for 14 years now.

  • David B. Reath, MD says:

    Carly,
    Thanks for your comments. Without seeing you, I cannot give you some definitive advice. However, with your decrease in body fat, you might do better with the implants placed under the muscle. However, the muscle will not prevent sagging.
    All the best,
    David B.
    P.S. To find a board certified plastic surgeon in your area, follow this link: http://www1.plasticsurgery.org/find_a_surgeon/

  • David B. Reath, MD says:

    Michelle,
    I am glad that the information has been helpful to you.
    All the best,
    David B. Reath, MD

  • Alexa says:

    Thanks for the well written article.
    I am scheduled to have a lift and implants. I have severe sagging breasts due to two pregnancies. I have been thinking if I can do without the lift or will I have big saggy boobs ? Silicone implants under the muscle.
    Feedback is appreciated.

  • David B. Reath, MD says:

    Alexa,
    Thanks for you comments. Here’s the bottom line; if you need a lift, you need a lift. Trying to avoid a lift by placing larger implants will only give you larger, sagging breasts. I have taken care of a number of women who have been down this road, and the answer is always the same. If you need a lift, you need a lift.
    All the best,
    David B.

  • Julie says:

    I’ve had implants over the muscle for 15years. Ive had no problems with them what so ever. However, I have now got alot of rippling and you can see the shape of the implants. I’m having my second BA next week but my surgeon has recommend me to have them under as the muscle as I have no fat or breast tissue. I run a lot and do weight training. I’m worried about the amount of pain I am going to be in as I’ve read horror stories on the Internet as my last BA over the muscle I had no pain at all. I’ve stopped doing any weights on my chest so they are not as tight. Is it true that the more tight the pectorals are the more pain your in, as I’m really nervous. Thanks in advance xx

  • David B. Reath, MD says:

    Dear Julie,
    Thanks for your questions. I think that you should definitely have your implants under the muscle if you are thin and have very little fat. Hopefully this will help with the rippling and the implants should not be as visible.There will be more pain with this than with your previous operation, but you should be able to handle this. I have never had a patient who could not. In about a week you will be about this same as if you have the implants over the muscle.
    Good luck!
    David B.

  • Sarah says:

    Hi there, I am a personal trainer and do lots of sports including weight lifting. I had very saggy breasts after nursing my son and 2 weeks ago I had an augmentation, silicone over the muscle.
    Its 2 weeks post op and I feel fantastic, can’t do sports yet but am back to daily life with very little discomfort.
    My PS recommended overs because I do so much sports, but reading this I am a little concerned that many people say they will look less natural over time and have higher risk of capsule contracture.
    I trust the decision of my PS but just wondered on a second opinion after reading this well informed article.
    Thanks, Sarah

  • David B. Reath, MD says:

    Sarah,
    Thanks for your email. Without seeing you, I cannot comment of what would be best for you. But since you have already had surgery, I would do nothing other than continue with your healing process. Chance are that things will work out well for you. Just keep up with massage and discuss any further concerns with your plastic surgeon.
    All the best,
    David B.

  • Elle says:

    I found your article very clear and professional exposing both placements.

    I started around a B cup and got 450 cc overs one year and half ago. They´re textured cohesive gel, rounds. I had no complications with the placement, got a great cleavage and like the size, my only concern is the firmness. I expected they´ll ending more softer and squishy than they´re now.
    If I downsize around 350cc´s this will improve in softness terms? Or It has to do with the textured cohesive implant? Thanks in advance!

  • David B. Reath, MD says:

    Elle,
    If you have highly cohesive gel implants which are textured and usually shaped (but not always) these will tend to be a little firmer than the usual cohesive gel implants. Sometimes implants over the muscle can be firmer than implants under the muscle.
    However, without seeing you I cannot really answer your question. However if you have firmness, it may be due to scar tissue (a capsular contracture) around the implant. This may need to be dealt with.
    Sincerely yours,

  • Karen R says:

    Great article Dr. Thank you!
    I do have additional question if you would be kind to answer me…
    I had silicone put under the muscle in in 2004 before kids. They are now sagging and I’ve had 2 doctors tell me I have a small case of “double bubble”. I am considering replacing them with over the muscle this time, but my doctor is telling me to put a larger size to avoid having to do a mastopexy. Will they still be saggy? Or should I go ahead and do a mastopexy? From previous articles I’ve read on over the muscle implants, I have a concern on how natural they feel… With the new silicones out in the market today do you still see that as an issue? Thank you in advance!!!!

  • David B. Reath, MD says:

    Dear Karen,
    Thank you for your email. Without seeing you, I cannot tell you what you should do. However, if you are sagging you will probably be better served by having a lift. Using larger implants to prevent the need for a breast lift is not a good way to go in most people. Usually the result is larger breasts that sag.
    If you have enough breast tissue, over the muscle can be a good option. Usually the current day silicone implants will feel fine as long as there is enough soft tissue coverage. However, if you have done well with implants under the muscle, it may be just as easy to keep them in this plane.
    Best of luck!
    David B.

  • Virginia says:

    Thank you for your informative article.

    I had breast implants about a year ago. Unfortunately the end result was not a natural look. My initial consultation was for a breast lift only but the surgeon recommended breast implants instead. Without really understanding the implant sizes I agreed to 375cc implants. The end result is overlarge breasts that have a tendency to sag if I dont wear a VERY supportive bra. I also have strange animation going on when I flex my muscles. I don’t know if the implants where placed under or over the muscle I just know that in order to get a more natural look I’ll have to start the process all over again. At least this time I’ll be able to make more informed decisions because of surgeons like you that take the time out to explain the pros and cons of each step. I’m glad I’m in the Tn area and I look forward to visiting your office in the future.

  • David B. Reath, MD says:

    Dear Virginia,
    Thanks for your comments. You most certainly have your implants under the muscle as you are getting an animation distortion. And it does sound like you need a lift.
    Without seeing you I cannot tell you exactly what your best option is, but I suspect that you could be well served by having a lift, and replacing your implants with smaller implants on top of the muscle. There is also a possibility that implants will not be needed.
    I look forward to meeting with you.
    All the best,
    David B.

  • Daniel says:

    Thanks for the info,
    I’m 18 and with average body type,my breasts haven’t grown properly up to this age,
    I have very small breasts,i wanted silicon tear drop implants on top of muscle cuz i’m kinda afraid of the pain of under muscle,
    I wanted to ask if it’s possible for me to have it on top of muscle according to my very small breasts?
    Thank u!

  • David B. Reath, MD says:

    Daniel,
    Thanks for your email. If you are very small breasted I would not advise you to have implants on top of the muscle. I think this could give you a poor result. The difference in recovery is not as much as you think.
    Also, I am not a fan of shaped implants for breast augmentation. I have used a few of these and have replaced about half with smooth, round silicone implants.
    All the best,
    David B. Reath, MD

  • mandie says:

    I’m a 28 year old mother of two. my son is just turning three months and my breasts barely got any larger during pregnancy and right back to a flattened wrinkly looking flapjacks. I have loose skin that looks like i’ve had a B cup but i never have went over an A. i cant even fit a AA bra right now I am so flat. I’m almost 5’10” and wider , more athletic build. (150lbs.) I want to know if i would be able to use saline or if im too small to consider it

  • David B. Reath, MD says:

    Dear Mandie,
    Thank you for your email. Without seeing you I cannot tell you for certain what can or cannot be done. However, you probably could have saline implants, most people have this as an option. However, it is likely that you will have a better result with silicone.
    All the best,
    David B. Reath, MD

  • Kate says:

    I have had 4 children and while nursing them I was a 34DDD but now I am less than an 34A. What would you recommend to fill the sagging skin? Under, over, a lift?

  • David B. Reath, MD says:

    Kate,
    Thanks for your question. Without seeing you I cannot tell you for certain what you need. But it sounds like you need a lift with implants under the muscle.
    All the best,
    David B.

  • Sapir says:

    Hi,
    I wondering if it possible to keep workout with weight and do push ups with implants under the muscles. Also, what is a good time to come back workout after the surgery?

    Thank you!
    Sapir

  • David B. Reath, MD says:

    Dear Sapir,
    Thanks for your questions. You can do push ups and return to weight work after having implants placed under the muscle. However, you will lose some muscle strength right after surgery which you will regain with time. You can get back into cardio workouts one to two weeks after surgery and return to weight work in about a month.
    Hope this helps,
    David B. Reath, MD

  • Smith says:

    Hi dr,

    I found your feedback invaluable thank you. Could you please tell me why you are not a fan of tear drop shape please? I met a girl who had round implants done and regretted not going for tear drop for a more natural look. Thank you

  • David B. Reath, MD says:

    Thank you for your comment and I am glad that you have found this blog helpful. I have used some tear drop implants and have replaced most of the ones I have used with round implants. I have found that the edge of the implants can be more easily felt and this has concerned some patients. Also these implants are significantly more expensive. And, I have found that the results I am able to achieve with the round implants are quite natural.
    Call me plain vanilla, but I am a fan of smooth round implants!
    All the best,
    David B.

  • Jasmine says:

    Dr,
    I already have fairly large breasts (DDs) but I’d like them to be slightly larger and fuller giving sort of a push up bra effect. What would you recommend? Would augmentation even work well on someone who is already pretty busty?

  • David B. Reath, MD says:

    Thanks for your question. Without seeing you I cannot give you specific comments. But with naturally large breasts, it is difficult to look like you do in a bra when you are not wearing one in terms of superior fullness. And, it is difficult for me to recommend that someone go larger than a DD.
    I hope this helps.
    David B. Reath, MD

  • Kat says:

    Hello! I am looking into getting my boobs done. I’m already quite busty (36D-ish) but I hate my shape and they’re saggy. I want a full but natural look. There is so much information on the internet! Don’t know where to even begin researching 🙁

  • David B. Reath, MD says:

    Dear Kat,
    Thanks for your comment. More than likely you will need a lift. There is a possibility that a modest implant could be used as well. But, if you are saggy, you will need a breast lift. Adding implants without a lift will only give you larger, sagging breasts.
    The eBook our staff wrote about breast augmentation is a great place to start your research. You can download it free here.
    All the best,
    David B. Reath, MD

  • Jessica says:

    Hello, I’m from the UK and due to have a breast augmentation next month. I have previously 12 years ago had a breast reduction. I went from a 28 GG to a 28 D I have since gone on to have 2 children one of which I breast fed. I also do a lot of cardio at the gym. I am 5’3” UK size 6 petite, and currently a 32 B/C I have excess skin on my breasts from breast feeding and working out but I’m not sagging. I love the shape of my breasts, I really don’t want that to change, I just want to be fuller.

    My surgeon has opted for 410cc Natrelle S high profile implants he said I could get away with bigger but I’m not so sure.. I can’t stress enough how I do not want them to look fake.. Natural as possible.

    Is there any advice you can give me, does the implant size sound sufficient for my frame?

    Thank you.

  • David B. Reath, MD says:

    Dear Jessica,
    Thanks for your email. As I am sure you can appreciate, I cannot really give you specific advice without seeing you. My thoughts are that the 410 cc implants will give you a D or possibly DD cup. And in my experience, a 401 cc implant is not overly big. Whether or not high profile is best for you is not something that I can comment on.
    If you have the ability to work with sizers with you surgeon, this can help you get a better understanding about how this size implant will affect you ultimate size and shape.
    I wish you all the best,
    David B. Reath, MD

  • Leah salinas says:

    I had a 32AA before my augmentation in 2012. My PS did 325 and 375 ccs under the muscle for me. I’m even and that was as large as he could possibly fit under the muscle. I do a lot of interval training and lifting. I cannot do heavy at all on bench presses and have to do very few push ups and always on my knees otherwise I have a lot of pain and pulling in my chest muscles. It’s very discouraging. The implants have totally changed how I feel and I love that I now have a more womanly look but really wish I didn’t have to modify chest exercises so much. Would switching to over the muscle be even something I can consider and would that fix my problem? At the end of the day I love that I can wear an adult bra and even though I’m still only a B I would rather be this way than before. Thanks for your help.

  • David B. Reath, MD says:

    Dear Leah,
    Thanks for your email. I cannot really comment on what your options are without seeing you. However, it does not sound like you have enough of your own breast tissue to make going on top of the muscle an option for you. However, if you have saline implants, changing to silicone implants may be of help. Also if your breasts are not soft, you could have a capsular contracture and dealing with this might help.
    All the best,
    David B. Reath, MD

  • Bailee says:

    I am a 32DD/34D but I have started looking into breast implants. How large could I reasonably go without looking like I have crazy large disproportionate breast. I’m 5’4″ and 120 lbs. I don’t want to go to large just want a bit more perkiness. What do you suggest?

  • David B. Reath, MD says:

    Dear Bailee,
    Thank you for your email. Without seeing you I cannot really advise you. However, it sounds like you already have good volume with a 32DD or 34D. If you want more perkiness, you may need a lift rather than implants.
    All the best,
    David B. Reath, MD

  • Amanda says:

    Hi…2 years ago I had my implants replaced with silicone. I wanted to have them put under the muscle as they have been over the muscle for 15 years and I feel are too round appearing and I have rippling. My surgeon told me going from over to under I was at risk for the implant to slip out of the pocket. I REALLY want them under the muscle…is this risky? Will under the muscle help with the rippling?

  • Cee says:

    Hi!
    I’m 30 and very unhappy with how my breasts look. I had a reduction about 6 years ago from a saggy 32 E to a nice 32c. I then came off the pill and lost some weight I now wear a 30b and due to the extensive scaring and the extra skin they don’t look good at all 🙁 I’m thinking of getting implants this year but people keep telling me to wait till I have children?? I’m 5ft and very slender on top. Any advice I’d be very grateful for?
    Thanks a Million!

    • Dr. Reath says:

      Hi Celine,
      Thanks for your question. If you are planning on having children it’s probably better to wait. Since you have excess skin you would most likely need a breast lift along with the augmentation. Pregnancy and breastfeeding could undo all the good results from your surgery.

  • Heather says:

    Hi Dr Reath!
    Let me just start with this option is amazing!! I highly appreciate being able to read through your questions and answers!! I do see that you highly recommend under the muscle for people like me. I am currently 32A, goal is 32C. I have augmentation scheduled March 17th. No lift, no plans for more kids. I have 2 children. Originally I had chosen over the muscle, but reading into your questions and answers, it seems under would be best for me. I do want the natural look, but want them to have cleavage and such without a bra. Not touching, but some cleavage! I have a second sizing appt this coming Monday and will make all final decisions then. I will either be going with 375CC or 400CC (both HP Mentor Implants). Do you recommend under the muscle? Obviously with what I’ve told you and not seeing me 🙂 Thank you very much!!

  • C.W. says:

    Thank you so much for this invaluable information. I have signed up to have a breast lift with smallish implants and my surgeon told me they would be over the muscle. I really didn’t know anything about the difference between over and under positions and had a vague impression that under is best. Your explanation has reassured me hugely. I have quite a lot of breast tissue and I can see that’s why I can have my implants over the muscles.

  • Dr. David B. Reath says:

    C.W.,
    I am glad that the blog helped you. I hope all goes well for your surgery.
    All the best,
    David B. Reath, MD

  • Kristi Miller says:

    About 10 years ago I had saline implants placed under the muscle. My question is, can I get a 2nd set of implants placed over the muscle as well? Or is it required to exchange the under the muscle implant entirely?

  • Kelley says:

    Hi Dr Reath,
    I found your explanation most helpful. I just had breast implants 2 days ago. My surgeon told me to do it over the muscle. I was a 34b. I wanted a full C cup and a natural look. He recommended that I get 385cc round gel implants over the muscle. What cup size will that make me and will they look natural when they settle down?
    Thanks in advance.

    • Dr. Reath says:

      Hi Kelley,
      Thanks for your interest. I am glad that you found this helpful. I wish I could answer your question, but without seeing you I have no way of knowing. It does take a while for the implants to settle but if you have concerns you’ll want to reach out to your own surgeon. All the best, David B.

  • Alexedward says:

    Breast implants come in shells that are either smooth or textured. Smooth implants have a thinner shell than textured ones. They may be less likely to ripple than textured implants, the surface of which can pull on the implant, causing wrinkling and rippling.

  • Ronita says:

    I was a A cup. I breast fed 2 babies so I went to a D.now I am a small B 105 pounds 5.2. Since my boobs stretched and went back down does that mean I should be able to go over the skin and get a full C? I want to get a lift to.

    • Dr. Reath says:

      Dear Ronita,
      Thank you for your comment. It sounds like you probably will need a lift however I can’t comment on your implant placement without seeing you. All the best.

  • Kym says:

    My implants are saline and under the muscle. They are also 27 years old. My question is about exercise. I was told to eliminate push-ups and handstand push-ups because I chose under the muscle placement. Does that advice still hold true?

  • RK says:

    Dear Dr.
    I am interested in getting silicone implants. I am quite concerned regarding future pregnancies and their effect on the breast (was never pregnant, but hopefully in the future). That said, should I go for a smaller size to have space for the milk dring pregnancy? Is there a way to prevent the breast from looking bad due to overstretch (my mom had a lot of milk when she was pregnant, and I believe I will too).
    I think of silicone – should I go over or under the pecs?

    Thank you!

  • Dr. David B. Reath,MD says:

    Dear RK,
    Thanks for your emails and questions. I do not believe that implant size will have any effect on milk production if you become pregnant. So I would not alter the size that you want now. I would go with what makes you look as you want now, and let the chips fall where they may once you become pregnant. There really is no good way to predict how pregnancy and breast feeding will affect your breasts. However, the more enlargement and the longer you breast feed, the more likely there will be stretching out of your breast tissue. Also wearing good support in your bra can be of help.
    In terms of over or under the muscle, I would need to see you an examine you to know for certain. However, I place more implants under rather than over the muscle.
    All the best,
    David B. Reath, MD

  • Vanessa says:

    Hello, I have very very little breast tissue. I’m barely an A. I do have a crease on the bottom though.
    Should I do silicone under the muscle? My main concern is looking natural, and no scars or ripples when I bend over. What about the different options on how to put them in i.e. under breast, arm pit, or via nipple? What do you recommend?

    Thank you,
    Vo

  • Parker says:

    Hello Dr. Reath,

    Thank you so much for this tremendously informative forum! I’m a mother of 2 with a current 34A breast size. I’ve had two consultations; 1 PS has recommended under the muscle while the other has recommended over which is what prompted me to look up the advantages and disadvantages of each. Based on what I’ve read here, I plan to go with under the muscle. My question/concern, however, is the ability to do certain exercises (push ups, handstand push ups, etc ) as I am into CrossFit workouts. Will these be a no-no with silicone under the muscle?

  • David B. Reath, MD says:

    Thanks for your question; it’s a good one. There are a couple of factors which play a part in this. Most women with submuscular implants can do push ups after they are fully healed and recovered. But it will feel a little different. Initially you will lose some strength but you should be able to recover this. The implants will be pushed a bit laterally with contraction of the pectoralis muscle. How much this will be a factor depends upon the shape of your rib cage. The wider the separation between the breasts and the more your rib cage slants laterally, the greater this effect will be.
    I hope this helps.
    All the best,
    David B. Reath, MD

  • Julie Henderson (Dallas-Oct 2017) says:

    Dr Reath,
    Thank you as your article. It’s comforting as I found your opinions and recommendations to many questions are very much the same as my own PS.

    After having kids, it was time for “me” so I had BA in 2005 with silicone /sub-muscularand with a lift and tummy-tuck. Due to capsular contracture, I just had a second BA. This time my PS placed cohesive silicone implants OVER the muscle to reduce risk of capsular returning.

    My recovery seems to be a little longer but I’m older so I expected. What I LOVE is I have no distortion when I do simple movements of pushing and lifting. I didn’t realize just how much this annoyed me.

    There are so many PSs who don’t take the time to fully include, explain and clarify…..not just the good info but also the unpleasantries and the risks that come with such a big decision.

    Thank You.

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