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Your Choices in Breast Implant Placement

Breast implants can be placed either directly under your natural breast tissue, which is called either subglandular or over the muscle placement, or under the pectoral muscles, called submuscular or under the muscle. These locations are frequently just called overs and unders. A full submuscular placement is a variation on unders, with the implant placed under the pectoral muscles and other muscles and tissue as well.

There are advantages and disadvantages with each of the breast implant placement choices. As with other options in breast implants, your choice of placement may be dictated by factors that are out of your control. Communication with your cosmetic plastic surgeon is key to making the choice that gives you the results that you want. You and your surgeon must be on the same page when it comes to what results you want. You and your surgeon should also discuss many factors, such as your lifestyle.

Remember that breast augmentation alone fills out your breasts, but does not change their general shape. However some procedures such as tubular breast deformity correction, areolae reduction, and breast lifts, can change the physical shape of the breast.

Pros and cons of subglandular breast implant placement

With subglandular breast implants  there is an increased chance of your (or someone else) being able to feel or see the implant. The edges of your implants may be apparent if you have little or no natural breast tissue, little body fat, and thin skin. However, some women prefer a high and tight look to their implants that can be achieved with overs placement.

One advantage of subglandular breast implants, is that this placement can be a quick fix for mild cases of breast sagging (ptosis)). However, it will not lift a breast that is sagging significantly,so if your surgeon suggests a breast lift, you should listen. Another advantage is that there is less pain postoperatively and a shorter healing time because the chest muscles have not been disturbed or rearranged during surgery.

Breast implant placement over the muscle also gives a more natural movement as you walk or use your chest muscles. With implants under the pectoral muscle, the muscle will squeeze or contract around the implant as the muscles are used. These movements can make the subpectoral breast implants look unnatural or twitchy, especially if you are doing something like lifting yourself into a boat, out of a pool, or onto a table and or while you are lifting weights.

Pros and cons of subpectoral breast implant placement

With subpectoral breast implants (also called unders, partial unders, or partial submuscular), the implants are placed under the natural breast and below the pectoralis major muscles that form part of your chest wall. Putting the implants under the pectoralis major muscle gives better implant coverage on the outer and inner top area of the implant, the cleavage area. If you have little breast tissue or would like a more natural look instead of a rounded, pronounced cleavage line and do not want rippling on the upper regions of the breast, then partial subpectoral placement may be for you.

Subpectoral breast implant placement surgery is a bit more involved that inserting subglandular breast implants under just the breast tissue. Under the muscle surgery involves the act of separating the pectoralis major muscle from the pectoralis minor muscle and chest wall and inserting the breast implant between these two muscles.

With this placement, some believe that the chance of developing capsular contracture is lower, although it is not impossible. One advantage for submuscular breast implants for many women and the one that clinches their decision is that the breast will have a more natural slope on the top if you have little natural breast tissue.

With subpectoral-only coverage the implant is not completely covered with muscle. The pectoralis major muscle branches fans out from your upper arm over the top area of your chest, but it covers only about the top two-thirds of the breast implant.  The bottom third to half of the implant is covered only by the breast tissue, just as in an over placement with subglandular breast implants.

In full submuscular breast implants (complete unders) placement, the implant is placed below not just the pectoralis major, but the pectoralis minor, the serratus, and the fascia (the connective tissue covering the muscle) of the rectus abdominal muscles of the abdomen. Even here, there is a small portion of the breast implant towards the lower inner edge that is not covered by muscle or fascia, especially with larger implants. But for ease of wording, we still refer to it as full submuscular breast implants placement or full unders.

The increased coverage of the implant with full submuscular breast implants is said to allow for virtually no rippling and a complete support of the implant. However, the fascia that is used for this placement can stretch out. Full under placement is not as common as other placements, but it is catching on. The chance of developing capsular contracture is reportedly much lower with full unders and the breast has a more natural slope on the top and no visible rippling on the sides and beneath the breast lobe than may otherwise be present in subpectoral-only placement.

One disadvantage is that with full submuscular breast implants placement, the breasts may appear high and tight and even somewhat square looking for a time, but patience is a virtue, and your breasts look good in the end. Patients with this placement say that it is worth it in the long run.

Some surgeons say that a full submuscular placement is possible with a transaxillary incision without any cutting of the pectoralis major muscle, which does heal in time if cutting it is needed. Some surgeons say that a full submuscular placement and a periareolar incision is possible with cutting of the pectoralis major. However, few surgeons offer full unders with a periareolar incision.  As I have said before, different surgeons have different opinions and methods regarding breast implant placement.

With full unders is that the surgeon has to take care not to snip the Cooper's ligaments (the ligaments that support the breasts) with a the transaxillary breast augmentation. If you are choosing this technique and placement, make sure your doctor mentions this risk to you at your consultation. It is rare with this technique, but it can happen.

The disadvantage of unders and full unders is a longer recovery time. Some say you will feel as if you performed too many butterfly curls with heavy barbells. Another disadvantage is that full submuscular breast implants placement does not allow for as many views (or images) of your breast during your mammogram.

You can almost describe full unders placement as an internal bra, since the rectus abdominus fascia and serratus muscle covers and supports the lower half of the implant. But you must remember that although the implant has some internal support, that support does not extend to your breast tissue and skin, so wear a bra to help prevent sagging

The diagrams show the approximate breast implant placement for overs, unders, and full unders.

“Lowering the Crease” or Lowering the Fold

If you have very small breast and want to go very much larger, you may need to have your natural inframammary fold moved or lowered. To get an idea of what this means, feel where your breast lobe meets your chest/rib cage. Now imagine this natural crease being between 1 to 1.5 inches lower than where it is now. Some people need even more lowering than this, depending upon their body and the size difference desired.

A few surgeons move the creases in women who have slight breast sagging to make their nipples point higher up, sort of like a pseudo-lift even if the creases do not need to be lowered. I personally do not agree with this, because it lowers the entire breast, but it may be applicable in some cases of pseudo-ptosis. Women with tubular breast also often need to have their mammary fold lowered.