Placement Over/Under Muscle

Among the many decisions that you will need to make before having breast implant surgery for augmentation or reconstruction is where the implant will be placed.  The three options are over, partially under, or fully under the pectoral muscle.  There are advantages and disadvantages, which are discussed below, to all of these.  Be sure to ask your surgeon for his or her professional opinion and which of these would be better for you.

Above the Muscle

Implants that are placed above the pectoral muscle (also called the “subglandular position”) function as a barrier between breast tissue and the muscle on the wall of the chest. The resulting look can be augmented and somewhat unnatural; however, not all patients see this as a disadvantage.

PROS

• Relatively easy to do so it should not be difficult to find a skilled surgeon.
• Patients often report less pain following surgery because the muscle has not been cut (just fat and skin).
• Easy to insert the largest sizes of implants.

CONS

• Can obstruct mammograms by as much as 40%.
• Elevated risk of capsular contracture (hardening of breast tissue around the implant).
• The edges of the implant may be visible or detectable through touch (especially if the woman selects implants with textured shells).
• Increased possibility of “bottoming out” (occurs when the crease of the breast lowers and the nipple may point upward – somewhat like “sagging”).
• May increase a woman’s difficulty with breastfeeding.

Partially Below the Muscle

With this placement (also called “partial submuscular”), the implant will be partially covered by the muscle (at the top) and come into contact with breast tissue at the bottom.  This placement is commonly done with the crease or nipple incisions.

PROS

• Does not usually interfere with mammograms.
• The implant edges are less visible.
• The final look will appear more natural.
• Risk of capsular contracture is reduced (assuming the implants have not come into contact with the natural bacteria on the ducts).

CONS

• More difficult to perform than “above the muscle.”
• Patients may have more pain following surgery.
• Carries a higher risk of bottoming out than the “fully below” technique.

Fully Below the Muscle

With this method, the implant goes completely below the patient’s pectoral muscle and does not come into contact with breast tissues.  Unlike the “partially below” technique, this one leaves connecting muscle at the bottom, which helps support the breast and keep it from bottoming out in the future.  Full under-muscle placement is best accomplished through the “armpit” incision.

PROS

• May increase the chances of being able to nurse a baby (Read more about Nursing with Implants).
• Likelihood of bottoming out and capsular contracture greatly reduced (the implant will not come into contact with breast ducts through the transaxillary incision).
• Creates a natural look.
• Decreased possibility of interfering with mammography.
• The implant is not visible.

CONS

• Because the procedure is more challenging, finding a skilled doctor may be difficult.
• More pain and/or discomfort for the patient after surgery because the muscle will have been cut.
• Increased discomfort until the muscle bridge that supports the bottom (the “support fascia”) stretches to accommodate the new implant.