When considering breast augmentation, one of the most important decisions is whether to place the breast implants above or below the chest muscle. There are pros and cons to both techniques that women should understand before making this choice. This article provides a comprehensive overview of over and under the muscle placement to help readers make an informed decision.
Quick Facts on Over and Under the Muscle Implants
Here are some key facts about the differences between over (subglandular/submammary) and under (subpectoral/dual plane) the muscle implant placement:
- Over the muscle implants are placed above the pectoral muscle and under the breast gland.
- Under the muscle implants are placed underneath the pectoral muscle.
- Over the muscle placement typically provides more cleavage and lift.
- Under the muscle placement feels more natural with less visible implant edges.
- Over the muscle has a faster recovery time with less pain.
- Under the muscle has a lower risk of capsular contracture.
- Over the muscle costs less on average.
- Under the muscle is recommended for women with little natural breast tissue.
Anatomy of Breast Augmentation
To understand the differences between the two techniques, it helps to first look at the anatomy involved in breast augmentation surgery. The breast is made up of fatty and glandular tissue overlying the pectoralis major muscle. This muscle runs across the chest below the breast. During surgery, the implant can be positioned either above or below this muscle layer.
With over the muscle placement, the implant is positioned in a pocket directly under the breast gland, on top of the pectoral muscle. With under the muscle placement, the implant is positioned underneath the pectoral muscle, either partially (dual plane) or completely covered by it (total submuscular).
Pros and Cons of Over the Muscle Implants
Here are some of the key advantages and disadvantages of choosing an over the muscle breast augmentation:
Pros:
- Faster recovery time with less pain and discomfort.
- Easier surgical procedure with shorter operation.
- No muscle cutting or release required.
- Can provide enhanced cleavage and lift of the breast.
- Less expensive procedure on average.
- Easier imaging for mammograms.
Cons:
- Higher risk of capsular contracture.
- More visible and palpable implant edges.
- Less natural feel compared to under the muscle.
- Not ideal for women with little breast tissue.
- Increased difficulty detecting breast cancer on mammogram.
Pros and Cons of Under the Muscle Implants
Here are some of the primary pros and cons with under the muscle breast augmentation:
Pros:
- Creates a more natural look and feel.
- Reduces risk of capsular contracture.
- Ideal option for women with little breast tissue.
- May be less likely to affect mammogram accuracy.
- Provides some support and lift to the breast.
Cons:
- Longer, more complicated surgery.
- Requires muscle release or cutting.
- Increased pain and longer recovery.
- Can sometimes appear less full or round.
- Costs more on average.
- Muscle can sometimes contract and squeeze implant.
Best Candidates for Each Implant Placement
The best candidates for each placement technique depends on a woman’s specific anatomy and cosmetic goals:
Over the muscle is ideal for:
- Women who desire significant lift and cleavage.
- Those with sufficient breast tissue to cover implants.
- Patients who prioritize faster recovery.
- Individuals seeking less surgical complexity.
- People concerned about cost of procedure.
Under the muscle is optimal for:
- Those with little natural breast tissue.
- Women who want a very natural result.
- Patients concerned about palpable or visible edges.
- Individuals at higher risk for capsular contracture.
- People prioritizing ease of mammogram imaging.
Recovery Comparison Between Techniques
The recovery process differs significantly between over and under the muscle augmentation. Here is an overview of what to expect with each:
Over the muscle recovery:
- Typically less pain and discomfort.
- Fewer activity restrictions after surgery.
- Drainage tubes removed 1-2 days after surgery.
- Return to normal activity within 3-5 days.
- Exercise and strenuous activity restricted 2-3 weeks.
- Fastest recovery of the two options.
Under the muscle recovery:
- More significant pain the first few days.
- Tight, restricted feeling in the chest.
- Drainage tubes remain 5-7 days on average.
- Slower return to normal activity over 1-2 weeks.
- Exercise restricted for 4-6 weeks.
- Complete recovery around 2-3 months.
Cost Comparison Between Techniques
Placing breast implants over the muscle is typically the less expensive option. Cost differences relate to:
- Shorter operating room time with quicker surgery.
- Faster recovery reducing post-op care needs.
- No muscle alteration required.
- Less pain medication and antibiotics needed.
Under the muscle placement costs more on average due to:
- Longer surgery duration under anesthesia.
- Muscle cutting or release procedures.
- Extended recovery requiring more follow-up.
- Higher medication costs for pain and infection prevention.
Many plastic surgeons charge $1000-$2000 more total for under the muscle augmentation compared to over the muscle. However, costs vary significantly based on the provider, patient needs, and implant type selected.
Implant Visibility and Palpability
The thickness of soft tissue covering the breast implants impacts their visibility and palpability. Key differences include:
Over the muscle:
- Less tissue covering with more visible and palpable implant edges.
- More likely to see and feel implant outline along top and sides.
- Some rippling or wrinkling may be visible.
- Best option for women with adequate breast tissue.
Under the muscle:
- Added muscle coverage creates a more seamless result.
- Reduces visible implant edges for a natural shape and feel.
- Less likely to see or feel outlines of implant shell.
- Ideal for those with limited breast tissue.
Risk of Capsular Contracture
Capsular contracture is a complication where scar tissue tightens around the implant, resulting in firmness, discomfort, and distorted shape. The risk factors include:
Over the muscle:
- Up to 2-3x higher risk of capsular contracture.
- Less tissue coverage means more exposure to bacteria.
- Subglandular placement provides an ideal bacterial environment.
- Contracture rates around 10-20%.
Under the muscle:
- Reduced risk of capsular contracture by up to 50%.
- Muscle coverage provides an added barrier to bacterial exposure.
- Contracture rates around 5-10% on average.
- Still possible to develop around lower breast tissue.
Breast Imaging and Mammograms
The placement of breast implants can impact the difficulty and accuracy of breast cancer screening. Key considerations are:
Over the muscle:
- Less obstructed view with implant on top of the muscle.
- Easier imaging and typically fewer additional views needed.
- However, implants can still obscure some breast tissue.
- Less surrounding tissue can make abnormalities harder to identify.
Under the muscle:
- Can require more views and special displacement techniques.
- Muscle coverage may obscure some breast tissue.
- But also enhances visualization of tissue near implant.
- Overall still very accurate when performed by a skilled radiologist.
Both placement options require informing the mammography technician about the presence of implants. 3D mammography provides better visualization around implants in either position.
Implant Movement and Rippling
The amount of friction and coverage of the implant also impacts the degree of movement or rippling:
Over the muscle:
- May allow more subtle shifting of implant position.
- Less tissue coverage makes rippling or wrinkling more visible.
- Recommended for women with adequate breast tissue padding.
Under the muscle:
- Muscle coverage helps restrict implant movement.
- Added friction minimizes any wrinkling or rippling.
- A good option even for women with less tissue.
Patient Satisfaction and Outcomes
Breast augmentation is known for very high patient satisfaction overall. However, some differences are seen between placement options:
Over the muscle satisfaction:
- 90% or higher satisfaction rates reported.
- Patients like faster, easier recovery.
- Natural, proportional results are still achievable.
- Some concerns over visible implant edges.
Under the muscle satisfaction:
- Over 95% of patients report excellent outcomes.
- Very natural shape and feel is appreciated.
- Women like absence of implant visibility.
- More difficult recovery is main drawback.
Overall cosmetic results are excellent with either placement when performed by a board-certified plastic surgeon. It is critical to follow all post-operative care instructions for optimal healing.
Which is Better for You?
The choice between over and under the muscle comes down to individual factors like:
- Existing breast tissue thickness and volume
- Cosmetic goals and implant size preferences
- Concerns over palpable or visible implant edges
- Prioritization of faster recovery and less pain
- Desire for added lift and cleavage
- Willingness to undergo more complex surgery
- Risk factors like smoking that increase complication likelihood
- Budget and cost considerations of the procedure
During your consultation, be sure to discuss all of these factors and priorities with your plastic surgeon. They can provide personalized recommendations based on your unique anatomy and objectives.
Frequently Asked Questions
Can I switch from over to under the muscle later?
Yes, a secondary breast revision surgery can convert implants from over to under the muscle if desired. This involves lifting the pectoralis muscle, creating a new implant pocket underneath it, and repositioning the existing implants. It is a more complex revision procedure but can be done to alter implant placement technique.
Which option looks and feels more natural?
Under the muscle typically provides the most seamless, natural look and feel. The muscle coverage helps conceal implant edges and restricting motion for a more anatomical shape and softness.
Is under or over the muscle better for nipple sensation?
Over the muscle augmentation is less likely to impact nipple sensation and nerve function. The surgery does not involve cutting or lifting the pectoralis muscle that supports nerves and blood vessels to the nipples.
Can I still breastfeed after each type of surgery?
Generally, yes. As long as surgical incisions avoid the breast ducts, both over and under the muscle implants should not impact the ability to successfully breastfeed after augmentation.
How is implant size affected by the two placements?
The chosen placement impacts optimal implant sizing slightly. Under the muscle allows for marginally larger implants, while over the muscle works best with more moderate implant volumes to prevent visible edges or rippling issues.
Conclusion
Ultimately, the decision between over and under the muscle breast augmentation is multifactorial. It depends on your specific anatomy, aesthetic goals, lifestyle factors, and surgeon recommendations. Both techniques are excellent options in the hands of a skilled, experienced plastic surgeon. Carefully weigh the pros and cons of each placement and have an in-depth discussion with your doctor to decide what is right for your unique needs and desires.
