One of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation (“overs”):

Subglandular augmentation means the placement of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular 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.

Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship-trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that the implant position does not interfere with the visualization of 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, implants placed superficial 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 are more likely to be able to perceive the implants and at higher risk of visible rippling when compared to subpectoral augmentation.

Subglandular implants can also create the illusion of improved cleavage by preferential over-dissection of the central/medial pocket allowing the implants to be forced more to the midline. There is no limiting muscle as there is in a submuscular augmentation.


Subpectoral Augmentation/Sub-muscular/Dual Plane (“unders”):

Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pectoralis 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 postoperatively by patients.

Subpectoral implants have a lower rate of capsular contracture.
Aesthetically, in contrast to submammary 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.

In my practice, the vast majority of patients will have the implants placed submuscular for all the reasons listed above.

As always, discuss your concerns with a board-certified plastic surgeon (ABPS).

Published on Jul 11, 2012

You will find each surgeon has their own preference in terms of where the implant is placed. By far, the vast majority place the implants under the muscle, and this would be my suggestion as well.

Over the muscle offers no support of the implant, causing them to feel heavy and to sag more easily over time, especially in those entering into the aging years. If you don't have a lot of breast tissue to cover the implant, you are more likely to feel and/or see any imperfections such as folds and ripples. There is also a higher rate of capsular contracture.

I offer a technique called complete muscle coverage, which is different than what most other plastic surgeons offer. The term "under the muscle" generally means partial coverage. My technique allows for the muscle to entirely wrap the implant, providing nice cleavage, full support, and keeps the implants from being able to migrate toward the armpits.

450 cc implants are quite large for today's standards. You are approximately a D cup right now. If you have a decent amount of breast tissue already, I would suggest a discussion about using a smaller implant size.

Best of luck,

Joseph Cruise, MD

Published on Jul 11, 2012