Which breast implant placement gives a more natural appearance?

In my San Francisco practice most of my patients have implants placed under the muscle. Creating a natural looking augmentation has many factors, all of which need to be addressed.

Some of these include (in order of typical importance):

Implant size
Implant shape (high profile, moderate profile, low profile)
Implant position (over, under the muscle)
Implant material
Incision placement

Your plastic surgeon should assess many factors including:
your desired outcome and size
breast volume
skin excess
breast diameter
skin quality
chest wall asymmetries

All of these (and more!) must be considered in creating a natural looking breast augmentation that will meet your expectations.

I hope this helps!

Steven Williams, MD

but Emzy nothing in breast surgery can be done in a word.  In general, because under the muscle placement provides an extra layer of tissue over the implants they are less apparent as implants.  It's like placing a comforter or blanket over a golf ball compared to placing a sheet over a golf ball, try it yourself.  Although this also generally results in a more "natural" appearance, it is not for everyone and many patients look just as natural with implants above the muscle.  A consultation with your board certified plastic surgeon will delineate the pros and cons of each placement position based on your needs and body characteristics.  This is a very individualized choice and all factors of your situation must be addressed to properly advise you of where to place your implants.  Good luck!

While the issue of ‘over’ or ‘under’ the pectoralis major muscle receives a great deal of attention, even more important than implant position relative to this muscle is implant position vertically and horizontally on the chest wall.  In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness.  In my Raleigh North carolina Plastic Surgery Practice, I regularly place breast implants below the muscle and above the muscle.

In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that an implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear ‘bottomed out’, with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast – another situation with a distinctly unnatural appearance.

The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Breast implant pockets that extend too fat laterally will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart.  If the pockets do not extend far enough laterally, however, the result is an augmentation with an abnormal ‘side by side’ appearance. As it is the lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an ‘hourglass figure’, careful attention must be paid to ensure that lateral breast projection is adequate and appropriate.

Another consideration is that the implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient who is 5’2” will be inadequate for a large-framed patient who is 5’10”. Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast enhancement.

I urge all propective patients to take time, do a lot of research and view many many before and after photographs before selcting a plastic surgeon to perform your breast augmentation. Taking some taime to speak to several former patients who have had the same surgery you are considering can also be helpful.

Michael Law MD

Board-Certified Plastic Surgeon

Raleigh, North Carolina

Hello,

"Unders" generally give you better long term results with both Silicone gel and Saline-filled implants. More coverage of the implants with healthy tissue makes a big difference over the long term.

Best Regards,

John Di Saia MD
Board-certified Plastic Surgeon

Natural is in the eye of the beholder.  However, the submuscular placement is the best option.  The benefits to going under the muscle are numerous.  Over time, the implants develop a capsule.  The tendency for this capsule to tighten or contract is much higher on top of the muscle not under.  The skin is not as strong as the muscle, so over time the implant on top of the muscle will droop significantly.  The chances of feeling or seeing ripples is much higher when the implant is above the muscle.

Most importantly, see pre and post op photos from the doctor.  Many surgeons will not release the muscle along the inner edge of the breast.  This will give you a very wide cleavage, which does not look natural.  A qualified Board Certified Surgeon should be able to make the breast look natural with a normal cleavage and base.

When patients tell my they want to look natural, I tell them they are natural, they just don't like it. Once you put in an implant, you are unnatural. The question is how to make them not look unnatural. Remember also that looks are only part of the naturalness. Feel, texture, and movement are other factors. In general, an implant over the muscle will move more naturally because that is where the breast tissue lives but an implant that gets hard or is too big will look unnatural. Implants under the muscle don't make much sense because there is nothing under the muscle normally except ribs, but it allows the tissues to hide the implant and statistically these implants stay softer for a longer period of time.  How you use the implants, what size and dimension you choose, and what you start with anatomically will all determine what you can achieve. Then you have to define what you mean by natural. Nowadays, what we often assume is a natural, attractive look is not "natural" at all.

As you can see, there are many opinions about the best placement of an implant.  Certainly, the patient's body habitus plays a role, but really only if you are looking for a reason to go above the muscle.  Remember, you can generally always go below the muscle in a first time augmentation patient. 

The only implant I would ever consider using above the muscle is gel because the salines are too wrinkly in that position, or are pumped up too full and hard to compensate for the ripples. 

But I would still put the gel or saline under the muscle anyway.  The look over time is less edgy, the capsular contracture rates seem to be lower, the implants are less easily felt and mainly, mammography radiologists say they always prefer to image a breast when the implants are separated from the breast gland by the pectoralis muscle.

You have asked a very important question--unfortunately, there is not one simple answer. There are many factors that come into play when determining where to anatomically place a breast implant. Most women desire a natural look and feel to their breasts.

Here are some of the good and bad points. In general most plastic surgeons prefer to place the implant beneath (subpectoral) your chest wall muscle (pectoralis major). The advantages are more of your own soft tissue covering the implant. This is desired as there is a smoother transition seen superiorly, above the nipple-aerolar area.

The added cushion of your muscle overlying the implant provides a softer feel and more natural appearance. Because of this added padding, we see a lower rate of complications related to infection and to internal scarring causing skin ripples, contour irregularities, or contractures.

In terms of protecting your chance of future breast feeding, there is a greater probability because the surgeon is operating in an anatomic plane beneath the gland-duct-nipple complex.

In terms of breast cancer screening and imaging, most radiologist prefer the implants placed in the subpectoral plane. There are disadvantages to placing the breast implants beneath the pectoralis muscle.

During the post-operative recovery period, there is more discomfort associated with this technique and it takes 3-5 days longer to heal. It is important to realize that when one flexes their pec muscles, there will be a flattening of the implants that can be noticeable, such as exercising or working out. If one has moderate or severe sagging, then this technique may make the breasts look even worse.

Usually, a breast lift (mastopexy) must be performed to correct this feature. The most common reason that I may suggest consideration to the implant placed on top of the muscle (subglandular) is when a woman who has small breast volume and moderate to severe breast sagging and DOES NOT want to undergo the breast lift procedure. This setting is most often seen when breast feeding several children over prolonged periods of time.

Lastly, if one is a professional athelete or competing a high level, I may recommend that they consider having their implants placed on top of the muscle with the understanding that we may convert them beneath the muscle at later time.

We women are incredibly aware of our breast appearance-- maybe even more than men are. Breasts are sexual and sensual, a big part of what makes us women, and they can dictate our sense of attractiveness and desirability (for better or worse). Breast augmentation is one of the top three most popular plastic surgery procedures performed. So many women embrace this procedure because it carries little risk of complication. And because an implant can be inserted through a tiny incision in the navel or armpit (and moved into place under the skin), or under the areola or breast, it's a quick, nearly scarless operation.

A major factor that effects how breast implants look and feel is whether they're inserted over or under the chest (pectoral) muscle. Traditionally I do a submammary implant, inserting the implants under the breast tissue and over the muscle because it's technically a lot easier (displacing the chest muscle requires a little more delicacy). It's also quicker: I insert the implant through an incision in the navel, nipple, breast fold, or armpit, place it over the muscle, and then inflate it when it's snugly in place. The result is fabulous: perkiness with barely a trace of scar.

If you want the most natural-looking breast you'll need a subpectoral implant, in which the implant is placed under the muscle. This procedure also requires the merest incision- about three centimeters in the crease under the breast or at the edge of the nipple-- and diminishes the incidence of capsular contracture, the formation of hard scar tissue around the implant which occurs in 10 to 30 percent of cases.

Subpectoral implants aren't right for everyone, though. If you have saggy breasts, and implant placed under the muscle won't fill out that empty breast sack, and you'll get what we call the "double bubble" look, where the implant is situated next to your armpit and the breast hangs several inches below it. Instead, you can have a procedure called augmentation mastoplexy, in which the implant is placed under the muscle and the skin on the breast is lifted and tightened.

In short, you must know--realistically-- what you are starting with, as well as what you want to look like when surgery is done. Do you care more about the placement of the scar or about a quick painless procedure? Do you want a natural appearance or a round, perky look? These are some of the factors I weigh with my patients when evaluating what type of procedure to do.

There is no standard approach to Breast Augmentation that works for all possible breast anatomical differences between patients. Placing the implant above the muscle is the appropriate choice in certain circumstances, and creates a natural result, whereas in other situations, implant placement above the muscle would be disastrous. Each approach involves some degree of trade-off or compromise, and the artistry of Plastic Surgery of the Breast is all about the surgeon making the correct analysis of the breasts and performing an elegant technical procedure with the appropriate choice of implants.

Similarly, the operation and the implants have their limitations, which should not be pushed by the patient or the surgeon. Implants above the muscle are generally not the appropriate single solution for sagging, ptotic breasts; a Mastopexy or Breast Lift, with implants, is more appropriate in most cases like this.

Your surgeon should formulate an individualized approach that takes into consideration your anatomy and the necessary limitations and compromises of each technique and implant, in order to arrive at a result that you will hopefully find to be both pleasing and natural.

Emzy,

This is a great question and you will likely hear many different opinions from many different people. That is because there is not a definitive answer and, depending on your body, the answers may be different.

Basically, the implants can be placed above the muscle (below the breast) or below the muscle (and the breast). The implant needs to have a sufficient amount of natural tissue covering it to maintain a natural shape. If you do not have much breast tissue and you put the implant above the muscle, then you will be able to see the implants and it will have an unnatural shape. In this situation, then placing the implant below the muscle gives more tissue coverage and a more natural shape. If you have plenty of breast tissue, then placing the implant above the muscle may be a nice option. However, if you have lots of loose breast tissue, then you may need the implant and a breast lift at the same time. In this case, it would be best to put the implant under the muscle and then perform the breast lift. My best advice for you is to go to a few consultations and see what the surgeons have to say. They will be able to give you good advice based on your body shape and amount of breast tissue.

I hope this is helpful.

David Shafer, MD
Shafer Plastic Surgery - Manhattan

The more tissue that covers the implant, the more the implant is hidden. Above the muscle implants tend to ripple more. The outline of the implant is typically much more visible above the muscle (and therefore unnatural). Above the muscle placement also destroys circulation from the chest muscle to the breast above it; this circulation never comes back and makes a subsequent breast lift (especially around the nipple) much more risky. The risk of developing scar tissue requiring reoperation is about double on top of the muscle.

In our practice, above the muscle placement may be suitable for competetive bodybuilders, for patients with sagging of the breasts unwilling to undergo a breast lift. For tubular breasts, we usually place smaller high profile implants below the muscle and perform a simultaneous lift to reduce the "snoopy breast" appearance.

Very large implants placed below the muscle can cause unfixable problems with the pectoralis muscle, which is often aggressively removed from the breast bone (sternum), causing an odd "jumping" of the muscle when it is used.

I hope this helps!

Brent Moelleken, MD, FACS
Private practice, Beverly Hills and Santa Barbara
Clinical faculty, UCLA

There are many ways to achieve exceptional results in breast enhancement. Implant type, positioning and incision placement all have an effect on the eventual outcome. Below the muscle placement generally results in the most natural appearance as it provides one more layer of coverage to the implants. Occasionally, in the case of breasts with moderate droop, a "dual plane" placement is better, as this technique avoids a "double bubble" deformity. Finally, some surgeons like the tear drop implants. I personally don't. Most women want superior pole fullness, and tear drop implants place the volume primarily at the bottom. Then finally, silicone cohesive gel implants provide the most natural feel, while minimizing the likelihood of rippling. I hope these thoughts help!

The short answer is that both planes can provide a very nice result, but the key is that your individual anatomy has to be evaluated and the advantages and disadvantages of each option reviewed.

A couple of other points to add:

In my opinion, saline implants should really not be used above the muscle as they will create a very unnatural look in most cases. If there is a need to place the implant above the muscle, I usually recommend silicone implants to my patients.

In my experience placing the implant above the muscle tends to give a more natural "settled in" appearance more quickly, versus placing it behind the muscle. I think this is important to realize and be prepared for if you do plan on having the implant placed behind the muscle.

The benefits of under the muscle placement outweigh the downsides.
First, when I talk about under the muscle, I am talking about a dual plane technique whereby the lower part of the implant is under the breast tissue and the upper part of the implant is under the muscle. If the implant is placed under the entire muscle, the implant is typically pushed out and down, spreading the cleavage unnaturally wide.
Second, the benefits of placing them in the dual plane position are many. a) decreased capsule contracture (hardening of the implants) when compared with above the muscle. b)Smoother implant edges to give a more natural result when compared with above the muscle implants. c) Less sagging over the long term. Face it - implants add weight and stress to your breasts that will add to the downward pull over time. When the implant is above the muscle, the breast tissue does not offer much support against the ravages of gravity. In contrast, the muscle on top of the implant adds significantly more support which bodes well for a more natural and durable result.
So what are the downsides to placing the implant behind the muscle. a) It hurts more during the postoperative period. b) some patients experience funny breast movements when they are contracting the chest muscles forcefully.
Would I ever place the implants above the muscle? yes, I will place them in front of the muscle in patients with Tubular breasts as part of a procedure to change the shape of an abnormal tube shaped breasts. I will also place them in this position for professional body builders.
Many doctors suggest placing the implant under the gland to improve a sagging or ptotic breast. I am opposed to this technique and suggest a lift for this problem. It is simple, if you are sagging - Fix the Sag.