Are Under-the-Muscle or Over-the-Muscle Implants Better?

If you are getting a breast augmentation, then one of the major decisions you will need to make is whether to put the implants under or over the muscle.  How to decide?   Like any decision, there are pros and cons to both methods.  

The pros of putting implants under the muscle are more coverage (less chance of seeing the implant), lower rate of capsular contracture (scar formation around the implant), and more upper pole fullness (if that is desired).  The cons of putting implants under the muscle are animation (movement of the implant when using the chest muscles) and more discomfort in the post-op period.  

The pros of putting implants over the muscle are less upper pole fullness, less of a natural look, no animation when working out, and minimal post-op pain.  The cons are increased implant visibility in thinner patients and possibly a higher rate of capsular contracture. 

Your plastic surgeon should help guide you through the process, but here is how I make recommendations.  First, pinch the tissue at the top of the breast. If it is less than 2 centimeters, I recommend placing the implant below the muscle to reduce the chances of seeing visible rippling.  If it is more than 2 centimeters, then think about how much you work out.  Do you do a lot of pushups and planks?  If so, over the muscle may be more comfortable for you.  

The next question is, do you want the implants to be higher up?  An implant under the muscle will lift the top of the breast by about 2 centimeters, where an implant over the muscle will lift by about 1 centimeter.  If you think you want implants over the muscle but are worried about visibility, we can make adjustments such as placing the implants subfascial (under the muscle covering, but over the muscle).  We can also use a firmer, more cohesive gel to decrease the chances of rippling.  

I do everything possible to reduce the chances of capsular contracture in all my patients, such as using no touch technique and a Keller funnel to avoid contact of the implant with the skin.  In patients choosing above the muscle, I also prescribe medication for 3 months to reduce the chances of capsular contracture.  For some patients who choose over the muscle implants, I may also recommend adding a mesh as an “internal bra” to provide additional support.  There is no right or wrong answer to this question; it is really a matter of figuring out the best option for you!