Which is better, over or under the muscle implants? Also, what's a good size?

I'm 56 y/o, breastfed 3 children, and lost almost 100 lbs by working out. I'm unsure which implant placement I should get and am equally confused about which implant size because I wear VS (32D) and those are not “true” sizes. My surgeon recommends over the muscle and said 450 cc gummies would yield a true full C or small D. It’s hard because I don’t know what a true D looks like and I keep hearing OTM is bad, that you can see/feel the implants and they aren't natural-feeling or looking.

Answers from doctors (2)


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).

Answered by The Institute of Aesthetic Surgery (View Profile)

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


More About Doctor Joseph Cruise, MD

Published on Aug 02, 2019

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

Answered by Joseph Cruise, MD (View Profile)

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


Related Questions for Breast Augmentation

Breast Augmentation -17 answers
I had breast augmentation 6 weeks ago and they seem to have settled but i'm unsure. I'm feel like they are too small. I have tried on bras and I measure into a 32DD as well as 34 C sister size (I was a 32a prior). How long will it take for my breast to drop and fluff? I also have a gap in between which makes it difficult to achieve cleavage.
See More
Breast Augmentation -9 answers
I'm worried my 400 cc silicone is too big. I liked the sizer and my doctor told me it would look smaller.
See More
Breast Augmentation -13 answers
I had a breast augmentation on April 8th. I feel like they are shaped funny and not as big as I wanted. I went submuscular. Prior to the surgery, I was a 38 B and now I have 560 cc silicone gel Inspira implants. I was hoping to be a DD. Should I have gone bigger? Will my breast take a more natural shape? When is a good time to get a new bra, and will I be a DD once my breasts have settled and healing is complete?
See More
Breast Augmentation -20 answers
I want the fake Barbie doll high projected look. I want to know what I am getting before I get my breast done.
See More
Breast Augmentation -19 answers
I thought I was getting 400cc high profile silicone but my PS said they'll be 400cc moderate plus. I wanted a natural but big look, a D cup, and a small gap. Maybe that's why he chose those? Is there much difference in projection?
See More
Breast Augmentation -13 answers
I just had surgery yesterday and I got 355cc's. They look so small in my surgical bra and wrap. I'm worried that they won't be big enough. Do you know what size I might be once the implants settle? I'm hoping small D.
See More
Breast Augmentation -15 answers
I have friends who've gotten 500cc's and their breasts are quite big. After trying the 650cc sizers, they seemed to compliment my body more. Is there a big difference between the two sizes? Is 650 too large?
See More
Breast Augmentation -14 answers
I'm a little lost on the XL implants matter, that I personally like. Are they really unsafe? What are the reasons for that? It seems most PS don't recommend/perform them. Is it by lack of experience/expertise? Idealism? Are those PS who perform these procedures just "warriors" responding to a well present market? I would be curious to hear some honest answers, leaving the politically/socially correct behind. Thanks in advance.
See More
Get answers from our experienced doctors.
How it works
Breast Augmentation -27 answers
I know there is a vast amount of factors that go into breast augmentation, lifts, and implant manufacturer costs alongside anesthesia, facility, meds, and other costs. But in your experience what is a ball park cost range you typically see for breast augmentation, and breast augmentation + lift. It'd be very helpful if you share a range like 9-10k or 6-7k, etc. Thanks!
See More
Breast Augmentation -19 answers
I am 5"4 and 145lbs. I am currently a 34C and would like to be a Dcup. My PS recommend a lift. I informed him i wanted implants but still want a natural look. PS recommended 485cc smooth moderate plus silicone obove the mucle. Possible mini lift during surgery depending on how the implant looks during surgery. It just sounds like a lot of CCs. It doesn't feel right and now I'm freaking out.
See More
Breast Augmentation -9 answers
Hi, I had surgery on 10/13/2016. I got 405cc hp under the muscle. My implants are high and they look square. Is this normal? When will they start to take their shape? They look smaller than what I expected. Will they get bigger?
See More
Breast Augmentation -10 answers
I am 5'7" and weigh 158 pounds. I want XL implants. My goal is to have a Barbie doll/Playboy model look. Based on my height and weight, would 1200cc or 1250cc help me achieve that? I want high projection and side boob.
See More
Breast Augmentation -13 answers
I was a full A, small B. My silicone implant size is 455 cc. What exacally is going to be my final size?
See More
Breast Augmentation -9 answers
I have so many stretchmarks from my boob job I hate them so much!!! I wanted to increase my bust size for confidence but now I am back at the starting point because I'm so self conscious of my stretch marks in constantly covering my boobs up. I need to do something to improve the colour of them as I'm quite tanned naturally they are so obvious in daylight.
See More
Get answers from our experienced doctors.
How it works

Related Articles

Have specific questions?
ASK A DOCTOR