Breast Implants Above or Below the Muscle: How Do You Decide?

By Dr. Scott W. Mosser

There are so many things for the patient and surgeon to decide regarding breast augmentation. Certainly implant size and incision choice are important, but one of the fundamental questions is whether the implant should be placed above the muscle or beneath it. It’s a fundamental issue that I help patients decide on during every consultation, but like many things in plastic surgery, different options will appeal to different patients, depending on their goals. Each option has risks and benefits that are a bit different, and I’ll try to explain the pros and cons a bit to help get you started deciding what’s right for you.

The ‘pros’ of going above the muscle are that there is much less movement of the implants during physical activity and there is a bit less discomfort on initial implantation. Above the muscle, the pain associated with surgery would be a bit less for the first 3-5 days after surgery, but then would level out and not be a significant difference. Implant movement is the appearance of a bit of movement of the implant (and therefore a bit of movement of the breast) when the muscles are flexed. Usually it’s hardly perceptible, but when a patient is engaged in significant physical activity (i.e. dancing or bodybuilding) in a bikini top or topless, there can be more visible implant / breast movement.

With submuscular placement only a few patients have implant movement with everyday activities. However, if implant movement during exertional exercise would be a big problem (such as with professional dancers) it’s sometimes best to avoid the risk and just go above the muscle. If necessary, implants can always be switched from above to below the muscle and vice-versa with a second procedure.

The ‘cons’ of going above the muscle are that 1) the appearance is more artificial in patients who begin with small breasts, 2) mammography is slightly less accurate when the implant is above the muscle as opposed to beneath it, and 3) the capsular contracture rate is higher. I’ll talk about each of these items a bit below.

Patients who start out with tighter skin or smaller breasts, and who are really looking for a natural look should seriously consider submuscular placement. The more of your own tissue that’s covering the implant, the more natural the appearance will be, and being beneath the muscle provides just that. Otherwise the implant is closer to the skin and the volume that can be added without creating an ‘augmented look’ is much smaller.

The benefit of more accurate mammograms from going below the muscle is small but might be a factor in your decision. A patient with a strong family history of breast cancer or who is very concerned about mammogram accuracy should take this into account when deciding on implant placement.

Capsular contracture is the hardening of some scar tissue that forms around the implant. This scar tissue (called the fibrous capsule) occurs at least a bit around all implants, but in some patients these capsules get hard and can deform the implants into a ball-like shape and even be come uncomfortable. We’re not 100% sure why, but the submuscular position seems toreduce the risk of getting a painful capsular contracture. This protection from capsular contracture is one of the strongest reasons for swaying me in the direction of submuscular placement. In fact, I recommend implants below the muscle for most patients. It just seems that the benefits of a more natural look and a lower risk of a painful capsule generally outweighs the risk of a small amount of potential implant movement during activities.

Of course, in the US we’re still using a lot of saline implants, and submuscular placement is also important to getting a more natural feel for most women who begin with small breasts and need saline implants. Perhaps someday when we get the silicone breast implants back on the market and this won’t be as much of an issue. Of course, submuscular placement will always help with decreasing the risk of implant contractures. For my perspective, I’d like to help my patients get the best chance they can get at avoiding them, so we always talk about this important factor in the decision. Postoperative massage has an important role in preventing contracture as well (ask your plastic surgeon about proper techniques and timing after surgery).

Some of the risks are the same for implant placement above or beneath the muscle. There is no difference between infection rates, rupture rates, nipple sensitivity problems or implant malposition (in experienced hands) for implantation beneath or above the muscle. There are lots of decisions, so in addition to implant placement, these important issues should be covered during your consultation as well. I’ll touch on more of these concerns in future articles. Until then, best of luck as you go through the process of discovering what’s right for you!

Copyright © 2006 by Dr. Scott W. Mosser. This article may not be copied or reproduced in any form without the written permission of Dr. Scott Mosser. Internet links to the sub-page containing this article are permitted.