Breast Implant Placement: Above or Below the Muscle?

Where Should One Place their Breast Implants? Above or Under the Muscle?

Implant Pocket Selection

One of the most important decisions prior to a breast augmentation procedure is the selection of the breast implant pocket.  The clinical manifestations of this may not be apparent for several years since the effects of the implant on your breast tissue may occur gradually.   Sagging of the breast may inexorably worsen, especially after giving birth and with aging.

Different Breast Implant Pocket Selections

• Total Submuscular (behind the serratus and pectoralis muscles of the chest)
• Partial Submuscular (behind the pectoralis muscle of the chest with its origin from the ribs left intact)
• Subglandular (above the pectoralis muscle of the chest)
• Dual Plane (partial submuscular and partial subglandular/submammary)

Total Submuscular

• Mostly a reconstructive technique
• Less commonly performed for a breast augmentation
• More painful
• More bloody due to the dissection during surgery
• The breast implant may have a tendency to rise superiorly

Submuscular Placement of a Breast Implant (Courtesy of Wikimedia Commons & Inamed)

 

Partial Submuscular (Under the Muscle)

• Breast animation and distortion may occur when the pectoral muscles contract.
• Lower incidence of capsular contracture.
• Risk of double-bubble deformity of the breast.
• More painful than a subglandular breast implant placement.
• Decreased risk of the palpability of the implant edges 
• Decreased risk of rippling
• It allows for better view during mammography.
• It's associated with a longer period of recovery, and more post-operative discomfort. 

Subglandular (Over the Muscle)

Subglandular Placement of Breast Implant (Courtesy of Wikimedia Commons & Inamed)

• Usually reserved for patients who have a substantial breast tissue or mild degree of ptosis (sagging of the breast.)
• May be the ideal choice for patients who are avid bodybuilders.
• The benefits of this position is the anatomic placement of the breast implant that is not affected by contraction of your chest wall muscles.
• A more natural appearance results with the placement of the implant subglandularly.
• There may be an increased risk for capsular contracture
• Implant palpability may occur when the soft tissues are very thin.  Thus, it is very important that the plastic surgeon assess the soft tissue of the breast before deciding to place the implant subglandularly.
• Faster recovery
• The cleavage is narrower with this technique.
• Larger implants may be able to be placed above the muscle.

• There’s a reduced tendency for the breast implant to ride high, and higher risk of seeing ripples (especially with saline breast implants.)

Dual-Plane Placement

Dual Plane Technique (Courtesy of Wikimedia Commons & Inamed)

• The breast implant is partially covered by the chest wall muscle.
• It allows for a more natural appearance while keeping the benefits of having the muscle cover the implant.
• The implant is less palpable and less rippling is observed.
• Pectoral muscle contraction may still occur with the dual-plane placement of the implant.
• There’s also a reduced tendency for the breast implant to ride high, as well as reduced tendency for the implant to lateralize.
• This technique has the benefits of both the subglandular and partial submuscular breast implant placement.
• The technique is more complicated than the subglandular and submuscular implant placement. 

 
Being a fully informed patient prior to your breast augmentation procedure is critical.  Learning the advantages and disadvantages of the techniques for breast implant placement are important, and this should be discussed with your plastic surgeon. 

Emmanuel De La Cruz MD, PLLC

Houston Breast Augmentation

References:

Sherrel Aston's Aesthetic Plastic Surgery 2009.

Hidalgo DA.  Breast Augmentation: Choosing the optimal incision, implant, and pocket plane.  Plastic & Reconstructive Surgery. 2000; 105 (6): 2202-2216

Takayanagi, et al.  Where should the implant be placed? Aesthetic Plastic Surgery. 2004; 28:83-88

Tebbetts JB.  Dual plane breast augmentation:  Optimizing implant soft tissue relationships in a wide range of breast types. Plastic Reconstructive Surgery. 2001; 107 (5): 1255-1272