Where Is the Best Place to Put a Breast Implant: Under or Over the Muscle?

Once you decide which incision to use for breast augmentation, the next decision is where to put the implant — over the pectoralis major muscle or under it.

Over the muscle is also called “subglandular” (under the breast gland), and under the muscle is called “submuscular.” Each tissue plane has advantages and disadvantages, so it’s important to consider your unique circumstances when making this decision.

At Halvorson Plastic Surgery, my primary goal is to ensure that every patient feels understood, respected, and confident in their choices. My practice is structured to allow ample time for consultations, ensuring that I thoroughly understand your unique needs and aesthetic goals. Building a relationship based on trust and open communication is fundamental to achieving a treatment plan that aligns with your expectations.

When it comes to breast augmentation, there is no one-size-fits-all approach. I believe in tailoring each procedure to the individual, considering your anatomy, lifestyle, and desired outcome. 

In this blog, we’ll explore the benefits and considerations of both subglandular and submuscular implant placement, helping you make an informed decision about what is best for your body and your aesthetic goals.

Advantages of Subglandular Implants (Over the Muscle)

The subglandular position is ideal when patients have some breast ptosis (aka “droop”) but don’t want a lift. In this situation, we are using the implant to fill out the breast skin, and we want the implant to sit lower on the chest where the breast is. One of the most critical tasks with breast augmentation is to center the implant under the nipple. So, when the nipple is a bit low, the only way to center the implant under it is to lower the implant. In these situations, if the implant is placed under the muscle (which is high on the chest), then the implant will be high, and the breast will droop over it. This is called a “waterfall deformity” or “Snoopy deformity” (named after the cartoon character’s profile). This is not a desirable look.

Some patients simply need a lift, and even a subglandular implant will not correct things. It is a big mistake to use a very large implant to fill out the skin of a severely drooping breast, as this simply leads to even more excess skin, a very artificial “done” look, and eventual surgery to correct things is very risky once a large implant has been used in this way.

Disadvantages of Subglandular Implants (Over the Muscle)

There are, however, several disadvantages to subglandular implants. First and foremost, there is a higher risk of capsular contracture. This is when the scar tissue that your body naturally makes around the implant starts to thicken and contract, causing deformity and pain. It’s not a huge increase in risk, but most studies do show a higher risk than submuscular placement of the implant.

The other disadvantage is that there tends to be a step-off or “bump” where the chest transitions to the breast in the upper chest. This is associated with a less natural breast profile. Some used to say that the subglandular implant results in less pain and easier recovery, but with the advent of multimodal pain management, there isn’t much of a difference, and most patients have minimal pain and a speedy recovery no matter what kind of breast augmentation technique is used. Even if there is a little less pain early on, this is not on its own a compelling reason to use this technique.

Advantages of Submuscular Implants (Under the Muscle)

The submuscular position, where the implant is placed beneath the pectoralis major muscle, offers several benefits that are particularly advantageous for certain patients. One of the primary advantages of submuscular placement is the natural appearance it often provides. When the implant is situated under the muscle, the additional tissue coverage can create a more gradual slope and a softer transition from the chest wall to the breast, leading to a more natural look.

Submuscular placement can be particularly beneficial for patients with thinner breast tissue. The muscle helps to mask the edges of the implant, minimizing the risk of visible rippling or wrinkling, which can be more pronounced in those with less natural breast tissue.

Submuscular placement also tends to have a more stable long-term position. The muscle helps to support the implant, reducing the chances of it shifting downward over time, which is known as implant bottoming out. This stability can contribute to longer-lasting aesthetic results and potentially fewer revision surgeries in the future.

Disadvantages of Submuscular Implants (Under the Muscle)

One of the disadvantages of submuscular implant placement is that it can result in minimal pectoralis major weakness and movement of the breast over the implant when the muscle contracts. Most patients do not notice this minimal change in muscle strength, and there is enough breast tissue above the implant that allows the muscle to be flexed without causing much of a deformity.

However, some patients do a lot of weight lifting and push-ups, etc., and these women might be bothered by this 10-15% decrease in pectoralis major strength. In thin, muscular women with smaller breasts and a moderate to large size implant, the movement of the breast tissue over the implant with muscle contraction can be bothersome and obvious in tight gym clothing.

Some women have had prior breast augmentation in the subglandular plane and have done very well, so when they have their implants replaced, it’s not a bad idea to just stick with the same implant position.

My Preference As a Plastic Surgeon in Asheville, NC

In the majority of primary breast augmentations, my preference is to use the submuscular plane.

First of all, there is a lower risk of capsular contracture. Second of all, it adds soft tissue over the upper pole of the implant, resulting in a smoother transition from chest to breast and a more natural profile. Although some believe that mammography is more reliable when implants are under the muscle, this has never been demonstrated in a scientific study.

When there is minimal ptosis (or “droop”), a “dual plane” technique can be used. This is when the subglandular plane is developed across the lower part of the breast, and then a submuscular plane is developed. As the lower part of the muscle is cut, the prior subglandular dissection allows the muscle to “window shade” or slide up a bit, letting the implant fill out the lower breast a bit more than it would if one simply cut across the lower pectoralis major muscle as in standard submuscular placement. Patients with minimal ptosis benefit from a dual-plane technique. With more ptosis, either a subglandular placement is required, or often it’s best to include a mastopexy (lift).

Some surgeons advocate using a “subfascial” plane. There is a thin layer of connective tissue (“fascia”) on top of the pectoralis major muscle, and in this technique, the fascia, but not the muscle, is elevated. Surgeons who have a lot of experience with this technique feel that it combines the advantages of both techniques. However, there aren’t any high-quality clinical studies that compare subfascial breast augmentation to other techniques.

In my opinion, this technique is not very different from the subglandular technique, so I still prefer the submuscular plane. However, my goal is to offer procedures that are in line with your individual preferences and goals, so there is never a one-size-fits-all solution. If you are considering breast augmentation in Asheville, please reach out to set up a consultation, and we will go over every decision to be made and come up with a plan that makes sense for YOU!

Learn More About Breast Augmentation, Revisions, and Other Procedures

According to data from the International Society of Aesthetic Plastic Surgery, breast augmentation is the most popular cosmetic surgery procedure for women — with 2.2 million procedures performed in 2022 alone.

Choosing the right implant placement is a critical decision in your breast augmentation journey, and it’s essential to have the guidance of an experienced plastic surgeon.

At Halvorson Plastic Surgery, we are dedicated to helping you make informed choices that align with your unique anatomy, lifestyle, and aesthetic desires.

I invite you to schedule a consultation with me to discuss your options in detail. During our meeting, we will take the time to understand your goals, answer all your questions, and develop a personalized treatment plan tailored to your needs.

My team and I are committed to providing you with the highest level of care and support throughout your entire experience.

Take the first step towards achieving the natural, long-lasting results you desire. Contact Halvorson Plastic Surgery today to book your consultation for breast implants in Asheville.