Breast Implant Below or Above Muscle

Breast implants can be placed either above or below the pectoralis muscle.  The decision of whether the implant should be placed placed below the pectoral muscle (subpectoral) or above the muscle (subglandular) depends on the patient’s breast type and preferences.  In reality, not all of the implant is below the muscle in a subpectoral placement, the lower outer implant is subglandular as the span of the muscle doesn’t cover this part of the chest.

Subpectoral breast implants (unders)subpectoral implant

When breast implants are placed subpectorally there is a little more soreness after surgery.  The muscle is stretched and the patient feels it.  The contracture of the muscle can cause ‘animation deformity’ with motion of the implants with flexion.  This can make subpectoral placement a less desirable choice for body builders or those with very strong pectoral muscles.

Subpectoral placement can result in a less rounded, more natural breast shape as the upper implant is compressed by the muscle in the upper chest.  This is either an advantage or disadvantage depending on the patient’s tastes.

There is a lower risk of rippling or wrinkling with the additional soft tissue coverage of subpectoral placement, particularly in the ‘cleavage’ area.   Thin patients with small breasts area at higher risk of rippling as a complication and subpectoral implants can be a better choice.

There has been proven to be a lower risk of capsular contracture in the subpectoral location.  The theory is improved blood supply and constant implant movement.

Mammography is less likely to be effected by the implant as the majority of the implant is separated from breast tissue by the muscle.

Subglandular breast implantssubglandular breast implant

The recovery can be a little easier and less painful after subglandular implants.  The pain is generally not too bad with either placement and choosing subglandular for pain and recovery alone would be a poor reason.

For patients who want a very rounded ‘fake’ look, subglandular results are generally less natural looking.  The exception to this rule is that tear drop shaped ‘gummy bear’ implants can result in a fairly natural appearance even in the subglandular position.  These implants do not rely on pectoral muscle compression of the upper pole to achieve a smooth, natural transition from chest to implant.

Probably the biggest advantage of subglandular implants is that some of the undesirable effects of going below the muscle can be reduced.  In particular, there is little to no animation deformity in the subglandular position.  Also, the implants can be placed a little closer together in patients with very wide pectoral muscle origins.  However, it is never appropriate to place the implants in a “push-up bra” position, nearly touching in the middle as the risk of symmastia is very high.

Subglandular breast implants can sometimes be helpful to give a little more ‘lift’ to the breast as the force of the implant isn’t dampened by the pectoral muscle.

The major disadvantages of subglandular implant placement are higher risks of capsular contracture, risk of bottoming out, and rippling.  With the addition of tear drop ‘gummy bear’ implants we now have an implant choice that can be used in the subglandular position that has a lower inherent risk of these complications.  In the U.S. it would not be surprising to find that more and more subglandular ‘gummy bear’ implants are being placed, a trend in Europe where these implants have been available for years.