Odd Man Out – Why I Favor Breast Implant Placement Above the Muscle

diagram of breast implant

When I was in training, every cosmetic surgeon that I worked with put breast implants below the muscle. The teaching was that this would contain the implant, isolate it from the breast, and offer more coverage on the upper portion. I was taught to perform the procedure that way, and continued in practice as one of many surgeons with that same training.

“Do Breast Implants Look Or Perform Better If They Are Under The Muscle?”

As I evolved in my own practice, I reconsidered many of the things that had been taught to me. Among them was the issue of where to place a breast implant. It had always seemed a bit strange to me that someone would take a device intended to mimic breast and put it where the breast does not exist. Yes, it is true that the muscle is under the breast, and putting an implant under the muscle does succeed in making the breast look bigger, but the breast tissue itself does not actually belong there.

“What Is The Benefit To Placing Breast Implants Above the Muscle?”

It also occurred to me that the muscle that is used for this purpose, the pectoralis major, normally lies flat on the ribs, tight and immovable. There is no space under this muscle, without cutting, ripping, and stretching it considerably. This same muscle also only covers about two thirds of the breast footprint, and especially after being pulled up to fit a large implant beneath it, it ends up only covering about half of the device anyway. What is more, even when maximally stretched, the muscle has the potential to contract, and this can cause a very socially awkward animation deformity that no one would want to display. The other issue with placement under the muscle is that, predictably, manipulating the muscle like that causes a significant amount of trauma to the area, and this leads to considerable postoperative pain, and longer recovery times. So why has this technique been the approach of choice for generations of surgeons? That is probably multi-factorial.

For one, surgeons like to keep it consistent. Once they are comfortable with a certain technique, it becomes a hard habit to break. Another reason is that, for decades, some of the complications associated with breast implants were attributed to contact with the native breast tissue. Having a barrier between the two was thought to prevent many types of problems, notably capsular contracture. But probably one of the most relevant reasons why this technique has been widely embraced is that, at the time of my training, the teaching was that the most common patient complaint after breast augmentation was that they had not “gone big enough.” As a result, surgeons placed the largest implants possible, and having that tight muscle layer to contain them actually did serve a purpose.

“Why Do Many Surgeons Prefer Breast Implant Placement Under the Muscle?”

In recent years, trends in breast augmentation have seen a remarkable shift. As I began to appreciate the relevance of placing a breast device in the breast plane itself, and as surgical techniques improved in terms of limiting complications from breast implant contamination with breast bacteria, the under-the-muscle technique has become less argued. That, coupled with recent trends towards natural results and teardrop shapes, has led to a revisiting of the procedures and a fresh perspective.

“Lead By Example – The Proof Is In The Profile”

There are circumstances where I would choose an under-the-muscle approach, such as when there is already a space made there and the patient is not having any issues with it. But on the whole, I prefer to go back to the basics and follow nature’s lead. As an art student and lifelong designer, my ideas and images of ideal forms are based in anatomy rather than habit; and my patients’ experiences dictate my preferences, even if this requires revisiting long-standing patterns. It is only through careful reflection and adaptability that we progress. And sometimes progress means going back to basics.

“Can Breast Implants Look Good Above the Muscle?”

Yes! Breast implants can look fantastic above the muscle. The key is to have them properly sized and positioned, and to choose the right type of implant for the patient. An oversized implant, or one with an imbalanced profile, will be harder to have sit right without the muscle literally holding it in place. But with the right choices and proportions, a well chosen implant can not only look fantastic above the muscle, but it can also move with the breast and simulate what it is supposed to simulate: more breast!


18 thoughts on “Odd Man Out – Why I Favor Breast Implant Placement Above the Muscle”

  1. Thank you for such an informative explanation. Here we are in 2021 and in 2020 I learned about Breast Implant Illness (BII). I’m 67 yrs. in 3 days. I had a career in law enforcement, working patrol and other details for 23 years in CA. I had Autoimmune hyperthyroidism (Graves) at age 19 and it was removed with radiation due to a goiter. That was in 1974. After nursing two 10lb babies, my A cup boobies looked like they were 80 years old. So in 1980 I had C cup implants.

    Since that time I’ve had AI vitiligo, Renauds , lichens, sjogrin’s, ringing in ears, hair loss, totally white hair, and brain fog. I thought it’s been all hereditary like the thyroid issue. (My dad had his removed for a goiter when he was 45 yrs). I Knew nothing of their placement or Silicone But in a 2011 mammogram it was reported one possibly was leaking. Although all my Mammogram reports went to an Oncologist (family history of breast cancer), never once did anyone mention this as potential problem, not even the female Oncologist. The oncologist has since retired. My current Rheumatologist for my AI Kidney said it didn’t look bad when I mentioned the rupture of one implant, it during a visit.

    So it wasn’t until 2020 I learned my fatigue and constant issues might be breast illness after my 43 yr old daughter mentioned bii and her friend having lupus. So
    I researched it. My explant will be 12/2021. I’m not afraid… can’t wait!

    It’s the anesthesia I can’t handle. I get deathly ill. Even when I explain my issues and get meds. They don’t help. So I’m willing to do anything to get them out. Dr says he believes they’re on top of the muscle which will be easier.

    I’m praying to regain my life after having these girls 41 years. I truly haven had any real energy in 15 years. I’m looking forward to feeling good. Thank you again for your info.

  2. Thank you for posting this! I have saline breast implants over the muscle. I am planning a breast lift this year, and have had discussions about if I should keep them over or put them under. I have very mild capsular contraction on one side. But there is no pain and they are still soft. Otherwise, over the muscle has served me well for the last 20 years. So many surgeons only go under the muscle. Luckily, I have had discussions that have given me the options, and one surgeon who actually recommends keeping them over the muscle, since that’s where they are now. Instead of making it a much more complicated procedure. so I’m continuing to do more research. But this helps me think that I’m going to go along with my gut and keep them over the muscle. Thanks! Makes a lot of sense to me.

    1. I have Saline otm for 23 years, I need a exchange now because 1 did leak. I’m getting otm again and Saline. best of luck to you. I just pray I don’t get CC again. these are my 2nd ones. My first ones CC but were textured and were replaced with these. that are smooth.

    2. I was wondering did you ever get your breast lift? I have been told that if you have implants over the muscle then I’m at higher risks for not healing well. What were you told?

    3. I had my implants placed over my muscle in 2020 after 2 kids ruined my natural dd lol I paid for the implants with a lift, so many ppl including a botox RN told me, he ripped me off and it’s not possible to do a lift over the muscle and he just shoved a big implants to fill up the space then cut the extra skin off.. but I paid /signed for a mastoplexy.. over the muscle gets so much hate and it kinda freaked me out but even the rn that told me I got ripped off liked how mine looked and we had the same size lol I dnt mind mine at all. I just hope they hold up.. for another 8 years atleast !

  3. Thank you for your post. This is helpful and I wish I knew this 11 years ago when advised by my surgeon to place Mentor saline implants under the muscle. I’ve had incredible pain and unexplained symptoms leading to BIIA. Planning my explant before August 2021. Hail to all that love their implants…and hail, peace & light to all on the road to recovery from their explant.

  4. Can a woman with little breast tissue (a cup with minimal tissue on top) have over the muscle implants that still look natural? I only want small implants ( large b, small c). I would prefer over the muscle but everything I’ve read is that under is better for women like me.

      1. I had mine under the muscle and it worked out great. they look like I haven’t had surgery at all. very natural. wish I could show you but I’d probably get reported for that lol I have to say though, they look and feel incredible, and very real!

    1. I am wondering the same thing. I’m very slim and small framed. I want to go for a small C or full C. My surgeon asked if I do chest workouts and I told him I want to only do lower body workouts but so he is going under the muscle. But now I want to do upper body as well so not sure if he should go over the muscle.

    2. My surgeon had the exact same thoughts as I just read in this article. I had VERY little existing tissue and went to a small D implant over the muscle. They’re still fairly new (8ish weeks) but look so much more natural than I even expected! My recovery was a breeze also

  5. Cathy it’s been 4 months so you might already had surgery. But my sister just had the exact thing your describing. Over the muscle bilateral mastectomy B cup. And has not had the exchange yet but the expanders so far look very real.

  6. Thank you for this. I have one question. Which would feel more natural to my partner. Above muscle or below? To me this is an important part of a natural result as the look. Thank you.

  7. I had saline implants above the muscle in 1995. I never had any issues and always liked how natural they looked. I have had a child and am now 53. The only change is they do seem more like natural breast because I have the normal sag of a natural breast. I’m going for a consult to have them replaced because they are soooo old. Ha
    I will only do over the muscle again. I was a large a, small b cup and went to a full c cup. Never regretted it. I prefer a natural look and not the super fake plastic look so many can have. Also prefer the safer saline over silicon.

  8. DO NOT place implants under the muscle. I have and utterly regret it. It creates scaring to your chest muscles and they will never ever be the same again. I have now removed my implants and I’m very glad I did. I wish I was made aware of the risks of going under the muscle as it was sold to me that it had no impact whatsoever. Think very hard before getting implants. BII is real and your body may never recover.

  9. Had over the muscle 395 cc silicone 6 years ago at 47 because I wanted a shorter recovery (my boobs looked like “rocks in a sock”, small B & a CrossFitter). Still love them & never had an issue.

    1. What was your recovery like? I’m scheduled for over the muscle this Friday. Have had two augmentations under the muscle, and hated the recovery along along with the animation deformity.

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