Breast implants: under or over the muscle?

“I’m so confused!  Should I have my breast implants placed under or over the muscle?  Which is best?”

I hear this question in my office every week.  There is an abundance of contradictory advice scattered about the internet on this subject, some good, some nonsense.  Having performed this procedure thousands of times over the 27 years I have been a plastic surgeon, I have come to realize that there is no one right way.  Each approach has its advantages and its disadvantages.  Which I recommend for a given woman depends on several factors which must be carefully sorted out.

Advantages of sub-glandular position

Sub-glandular placement (in front of the muscle) is less painful, and is a more natural location for the implant (there is no breast tissue behind the muscle).  If capsular contracture (thickening and tightening of the fibrous tissue around the implant) occurs, it is more easily corrected than if the implant is sub-muscular.  Distortion of the breast with muscle contraction, which occurs with sub-muscular placement, is absent with sub-glandular placement (see video link below).

Advantages of sub-muscular position

The primary advantage of sub-muscular placement is an increase in soft tissue coverage of the upper, inner portion of the implant.  This may be of benefit in women whose tissues are particularly thin in this area.  Interference with mammography may be slightly decreased compared to sub-glandular placement, and capsular contracture may be slightly less common than with sub-glandular placement.

The primary disadvantage of sub-muscular implant placement is the unnatural movement of the muscle and breast with arm motion.  This is visible in swimwear and summer clothing, and is a tip off that breast implants are present.  Many women are not happy with this movement, and I have converted numerous women from sub-muscular to sub-glandular position to correct this.  Click on the link below to see a video clip of this movement.  Women in this video all have implants in a sub-muscular position.  At rest, they look normal.  With flexion of the muscle, there is some distortion of the breast.

Sub-muscular

 During the consultation I measure pinch thickness of the tissues in the upper, inner quadrant of the breast, and tend to favor sub-glandular placement if tissues are of adequate thickness, sub-muscular if not (for women not put off by the movement).

Mark D. Ball, M.D., F.A.C.S.