What's the difference between putting the implant behind the muscle and putting it in front of the muscle?

I want to know which one makes you look fuller and doesn't leave you with a big gap between the breasts.

Answers from doctors (8)


More About Doctor Alton E. Ingram, MD

Published on Apr 20, 2021

This is a great question! Breast implants are fake, and breasts are in front of your pectoralis muscles. So ... your best result, if you want to look natural, and all things being equal, is to have the least fake implants (silicone) put in the normal place (in front of the muscle). However, some people don’t want silicone, some people don’t have enough tissue (2 cm or so) in their upper poles to camouflage the implants, and old data indicate that behind the muscle can lead to fewer grade 3 and 4 capsular contracture. But ... silicone in front of the muscle absolutely will make you look fuller (not “faker”) and will leave a smaller gap between your breasts.

Answered by Alton E. Ingram, MD (View Profile)

This is a great question! Breast implants are fake, and breasts are in front of your pectoralis muscles. So ... your best result, if you want to look natural, and all things being equal, is to have the least fake implants (silicone) put in the normal place (in front of the muscle). However, some people don’t want silicone, some people don’t have enough tissue (2 cm or so) in their upper poles to camouflage the implants, and old data indicate that behind the muscle can lead to fewer grade 3 and 4 capsular contracture. But ... silicone in front of the muscle absolutely will make you look fuller (not “faker”) and will leave a smaller gap between your breasts.

Published on Jul 11, 2012


More About Doctor Harry Glassman, M.D.

Published on Feb 06, 2019

There is no definite answer to this question. The decision about whether to place the implant under or above the muscle depends on the patient's anatomy and the degree to which their breasts may be sagging. Both approaches are capable of creating fullness and avoiding a large space between the breasts. There are, however, limitations based on the individual's anatomy, breast size, and shape as well as the shape of their sternum and ribs.

Answered by Harry Glassman, M.D. (View Profile)

There is no definite answer to this question. The decision about whether to place the implant under or above the muscle depends on the patient's anatomy and the degree to which their breasts may be sagging. Both approaches are capable of creating fullness and avoiding a large space between the breasts. There are, however, limitations based on the individual's anatomy, breast size, and shape as well as the shape of their sternum and ribs.

Published on Jul 11, 2012


Tim Sayed MD, MBA, FACS

Published on Aug 09, 2017

The risk of capsular contracture (tightening scar tissue that can distort the appearance or cause pain) is lower when the implant has more tissue coverage, so under-muscle or so-called "dual plane" is the standard for most patients. The gap between the breasts is mostly determined by the width of your breastbone.

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Answered by Tim Sayed MD, MBA, FACS

The risk of capsular contracture (tightening scar tissue that can distort the appearance or cause pain) is lower when the implant has more tissue coverage, so under-muscle or so-called "dual plane" is the standard for most patients. The gap between the breasts is mostly determined by the width of your breastbone.

Published on Jul 11, 2012


More About Doctor Tom Pousti, M.D.

Published on Jun 13, 2017

Every patient differs regarding what will help them achieve their goals (due to their anatomy), but I generally recommend under-the-muscle breast augmentation for longer lasting, nicer results.
Best wishes.

Tom Pousti MD
www.PoustiPlasticSurgery.com
619-466-8851

Answered by Tom Pousti, M.D. (View Profile)

Every patient differs regarding what will help them achieve their goals (due to their anatomy), but I generally recommend under-the-muscle breast augmentation for longer lasting, nicer results.
Best wishes.

Tom Pousti MD
www.PoustiPlasticSurgery.com
619-466-8851

Published on Jul 11, 2012


Stephen Greenberg, MD

Published on Jun 06, 2017

Thank you for your question.

We can place implants in the sub-muscular (behind the muscle), or sub-glandular/sub-mammary (in front of the muscle) position. In my practice and years of experience, implants in the sub-muscular position do much better long-term, have lower complication rates (such as capsular formation), and provide a more natural look and feel when compared to sub-glandular or sub-mammary implants.

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Answered by Stephen Greenberg, MD

Thank you for your question.

We can place implants in the sub-muscular (behind the muscle), or sub-glandular/sub-mammary (in front of the muscle) position. In my practice and years of experience, implants in the sub-muscular position do much better long-term, have lower complication rates (such as capsular formation), and provide a more natural look and feel when compared to sub-glandular or sub-mammary implants.

Published on Jul 11, 2012


Edward Domanskis M.D.

Published on Jun 06, 2017

The shape of your breasts after a breast enlargement really depends on the shape before. It just acts as a filler. When I put the implant behind the muscle, you do end up with the muscle contraction deformity when you flex your muscles so I prefer on top of the muscle, especially in someone who has sagging breasts to give a more natural appearance but I totally individualize explaining the various advantages and disadvantages of each.

Dr. Edward Jonas Domanskis is Certified by the American Board of Plastic Surgery
Newport Beach, San Francisco,Miami, Italy, Anguilla
949.640-6324/1.888.234-5080(Ca)
FAX- 949.640-7347
Website: http://www.surgery-plastic.com
Assistant Clinical Professor of SurgeryWOS-Plastic,University of California (Irvine)
Orange County’s Physician of Excellence/America’s Top Physicians/Top Doctors
Plastic Surgery- 2005-2017
President,American Society of Bariatric Plastic Surgeons
www.ASBPS.org
Organoderm Skin care/ScaRxTape

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Answered by Edward Domanskis M.D.

The shape of your breasts after a breast enlargement really depends on the shape before. It just acts as a filler. When I put the implant behind the muscle, you do end up with the muscle contraction deformity when you flex your muscles so I prefer on top of the muscle, especially in someone who has sagging breasts to give a more natural appearance but I totally individualize explaining the various advantages and disadvantages of each.

Dr. Edward Jonas Domanskis is Certified by the American Board of Plastic Surgery
Newport Beach, San Francisco,Miami, Italy, Anguilla
949.640-6324/1.888.234-5080(Ca)
FAX- 949.640-7347
Website: http://www.surgery-plastic.com
Assistant Clinical Professor of SurgeryWOS-Plastic,University of California (Irvine)
Orange County’s Physician of Excellence/America’s Top Physicians/Top Doctors
Plastic Surgery- 2005-2017
President,American Society of Bariatric Plastic Surgeons
www.ASBPS.org
Organoderm Skin care/ScaRxTape

Published on Jul 11, 2012


Joseph Cruise, MD

Published on Jun 06, 2017

Great question. There are actually several different placement options. Above muscle, under the muscle, and complete muscle coverage. I almost always perform complete muscle coverage with my breast augmentations because it provides the best cleavage out of all techniques. Under the muscle isn't really completely under the muscle as it implies. It is actually just partially covered. This technique tends to leave a gap between the breasts, which most women don't like. With a large enough implant to close the gap, over the muscle can achieve nicer cleavage than the standard under the muscle technique, especially with use of a bra. However, with this technique there is no muscle support, so the breasts can migrate laterally.

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Answered by Joseph Cruise, MD

Great question. There are actually several different placement options. Above muscle, under the muscle, and complete muscle coverage. I almost always perform complete muscle coverage with my breast augmentations because it provides the best cleavage out of all techniques. Under the muscle isn't really completely under the muscle as it implies. It is actually just partially covered. This technique tends to leave a gap between the breasts, which most women don't like. With a large enough implant to close the gap, over the muscle can achieve nicer cleavage than the standard under the muscle technique, especially with use of a bra. However, with this technique there is no muscle support, so the breasts can migrate laterally.

Published on Jul 11, 2012


When undergoing breast augmentation, there are many choices that need to be addressed: saline or silicone? Larger or smaller volume? Type of incision?

One of the most commonly debated choices is choosing between sub-glandular/sub-mammary and sub-pectoral/sub-muscular? While many surgeons recommend sub-muscular placement, there are distinct differences between each approach.

Sub-glandular Augmentation (“overs”):

• Sub-glandular augmentation means placing the implant underneath the breast tissue but above the pectoralis muscle. Sub-glandular placement spares the pectoralis muscle which leads to reduced post-operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster compared to sub-pectoral augmentation.

• Sub-glandular augmentation can impact mammograms. However, as dedicated breast radiography is more prevalent these days, this has become less of an issue. Fellowship-trained radiologists are now familiar with evaluating breasts post-augmentation. Bear in mind that implant position does not interfere with visualizing breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).

• Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.

• Aesthetically speaking, implants placed superficially to the pectoralis major create a rounded, convex-appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However as a woman ages, fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly have a higher risk of conspicuous implants and at higher risk of visible rippling.

Sub-pectoral Augmentation (“unders”):

• Sub-pectoral augmentation is technically a bit of a misnomer. Traditionally, sub-pectoral augmentation involves releasing the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes to much of the discomfort encountered post-operatively by patients.

• Sub-pectoral implants have a lower rate of capsular contracture.


• Aesthetically, in contrast to sub-mammary implants (which are prominent in the upper pole, especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.

• The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

With regards to your specific question, the gap between your breasts is defined not by the plane of augmentation but by the unique features of your anatomy. If your breasts are widely spaced, then placing your implants behind the native mound will achieve a similar but augmented result. Implants placed over the muscle can be forced artificially to the middle as there is no limiting muscle but this may lead to a disconnect between the native mound and the implant.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other. As always, your board certified plastic surgeon can help guide you in your decision making process.

Answered by The Institute of Aesthetic Surgery (View Profile)

When undergoing breast augmentation, there are many choices that need to be addressed: saline or silicone? Larger or smaller volume? Type of incision?

One of the most commonly debated choices is choosing between sub-glandular/sub-mammary and sub-pectoral/sub-muscular? While many surgeons recommend sub-muscular placement, there are distinct differences between each approach.

Sub-glandular Augmentation (“overs”):

• Sub-glandular augmentation means placing the implant underneath the breast tissue but above the pectoralis muscle. Sub-glandular placement spares the pectoralis muscle which leads to reduced post-operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster compared to sub-pectoral augmentation.

• Sub-glandular augmentation can impact mammograms. However, as dedicated breast radiography is more prevalent these days, this has become less of an issue. Fellowship-trained radiologists are now familiar with evaluating breasts post-augmentation. Bear in mind that implant position does not interfere with visualizing breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).

• Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.

• Aesthetically speaking, implants placed superficially to the pectoralis major create a rounded, convex-appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However as a woman ages, fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly have a higher risk of conspicuous implants and at higher risk of visible rippling.

Sub-pectoral Augmentation (“unders”):

• Sub-pectoral augmentation is technically a bit of a misnomer. Traditionally, sub-pectoral augmentation involves releasing the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes to much of the discomfort encountered post-operatively by patients.

• Sub-pectoral implants have a lower rate of capsular contracture.


• Aesthetically, in contrast to sub-mammary implants (which are prominent in the upper pole, especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.

• The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

With regards to your specific question, the gap between your breasts is defined not by the plane of augmentation but by the unique features of your anatomy. If your breasts are widely spaced, then placing your implants behind the native mound will achieve a similar but augmented result. Implants placed over the muscle can be forced artificially to the middle as there is no limiting muscle but this may lead to a disconnect between the native mound and the implant.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other. As always, your board certified plastic surgeon can help guide you in your decision making process.

Published on Jul 11, 2012


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