There are pros and cons to placing the implant either behind or in front of the pectoral muscle. In this article, Paramus breast enhancement surgeons Gary D. Breslow, MD and Jordan P. Farkas, MD describe these two different approaches, and offer their advice on choosing the option that is most suitable for you.

Submuscular vs Subglandular: What’s the Difference?

When we hear that a breast implant can be located over or under the muscle, this actually refers to where the implant is placed in relation to the three layers of the chest wall: muscle, soft tissue, and skin. All breasts — natural and artificial — owe their unique form to a combination of these three tissues.

• Structural tissue provides a “footprint” for the breast and tethers it to the chest wall.
• Soft tissue plumps the breast and provides its pliable form.
• Skin drapes the breast and molds to the soft tissue, although it’s not a structural support.

During surgery, the soft tissue of the breast is augmented with a saline or silicone implant. The structural tissues that support this implant include the serratus and pectoralis muscles, which normally provide a base for the soft tissue of the breast against the chest wall.

In the average women who hasn’t done extensive bodybuilding, the pectoralis muscle is relatively thin (less than ½ inch) and flexible. This allows it to be either be left in place, pulled forward completely to create a pocket for the implant, or partially pulled forward to create a half-pocket for the implant.

• When we speak of “subglandular” or “prepectoral” placement, this refers to the implant being placed over the pectoralis muscle of the chest, where it is covered by the soft tissue and skin of the breast.
• “Submuscular” placement is performed when an implant is completely tucked away under the pectoralis and/or serratus muscles of the chest. In these cases, the implant is actually under all three layers of the breast — muscle, soft tissue, and skin.
• A combination of both approaches called “Dual-plane” placement can also be performed: this is when the implant is tucked halfway under the pectoralis muscle. In these cases, the top of the implant is actually under all three layers of the breast, while the bottom is only covered by the breast’s soft tissue and skin.

Over the Muscle: Pros and Cons

Depending on the type and size of implant you’re interested in, there are definite advantages and drawbacks to subglandular placement.

Firstly, soft tissue and skin are capable of stretching more than muscle. This means that there is room for larger implants when they are placed in front. Over the muscle placement also tends to give more predictable results in the final breast contour, since the soft tissue and skin are more likely to mold to the outline of the implant.

Having the implants placed over the muscle is also less invasive: since the muscle is not cut, there is a lesser risk of it being injured or losing its strength. Lastly, this surgery can be done via an incision in the umbilicus (belly button), which can greatly reduce scarring.

There are drawbacks, however. Everyone heals differently, and sometimes soft tissue can harden in response to stretching and begin to form fibrous tissue. This is known as “capsular contracture,” because the capsule around the implant contracts, becoming thick and puckered like a scar. When this occurs it can sometimes cause pain and a deformation of the implant. Capsular contracture is more likely when implants are placed in front of the muscle.

And because soft tissue is more pliant than muscle, the implant may be more apparent if the patient has less soft tissue to cover it. This can cause vertical folds — also known as “rippling” — to appear on the lateral surfaces of the breast.

Women who have a limited amount of overlying natural breast tissue in relation to the implant size are more likely to experience breast implant rippling. Consequently, it is most common in the following cases:

• Women with very large implants
• Women who are very slim
• Cancer survivors who had extensive resection prior to breast implant surgery

Under the Muscle: Pros and Cons

In recent years the techniques employed to place implants behind the pectoralis muscle have evolved in response to concerns about capsular contracture and breast implant rippling.

Additional benefits have also been discovered, including reduced rates of sensory loss in the nipple and areola, greater visibility of native breast tissue during mammography, and a reduced likelihood of hematomas (bruising) near the implant after surgery.

However, there are drawbacks to this approach. Placing the implant under the muscle reduces the potential size of the breast. Patients also report increased postoperative pain because the muscle has been disturbed, and because of the plane of the muscle, sometimes the implant will migrate to the side.

It can also be more difficult to attain significant cleavage with a submuscular placement. The muscle must be thinned near the breastbone to achieve this effect, leading to an increased risk of eventually developing symmastia in thin patients.

As previously discussed, in “dual-plane” placement the implant is only behind the muscle on its upper-half. This can occur if the pectoralis is not large enough to cover the implant completely, or if it’s cut intentionally. In some cases, the top half of the muscle will pull upwards when it is flexed, leading to a complication known as “animation deformity.”

In addition to the risks described above, any surgical procedure carries a risk of scar formation, infection, and body fluids building up at the surgical site.

RELATED: What Is A Uniboob? Symmastia Explained

What Breast Implant Placing Technique Is Best?

Unfortunately, there is no cut-and-dried answer to that question: it is important to have a consult with an experienced plastic surgeon before you decide on any given approach. The best placement for you will depend on your body, overall health, previous surgeries, and your desired aesthetic outcome.

Plastic surgeons take a professional pride in their patients’ satisfaction, and part of this involves making a clear plan for surgery. During your initial consult, the surgeon will assess your breast’s natural form and inquire on any previous surgeries. After this, he or she will explain the range of surgical procedures available to you, detail the expected results, and inform you of any potential risks. Only then can options be tailored to address your individual aesthetic goals.

Also bear in mind that breast augmentation techniques have greatly improved since the procedure was first performed in 1962, and that as time goes by we collect more long-term data from patients. This means that while plastic surgery procedures are becoming increasingly safe and standardized, many surgeons still stick to the techniques that they are most familiar with, regardless of what’s best for the individual patient.

Drs. Gary D. Breslow and Jordan P. Farkas are widely recognized as leading authorities in breast enhancement surgery, and have successfully performed breast augmentation procedures on numerous patients from New Jersey and beyond. If you are still uncertain of the best approach to take, feel free to reach out to us for a consult.

Additional Reading and References

• BBC News: A Brief History of Breast Enlargements
• Medscape: Submuscular Breast Augmentation Treatment & Management, Surgical Therapy
• Archives of Plastic Surgery: Capsular Contracture after Breast Augmentation: An Update for Clinical Practice