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Breast Implant Placement FAQ

This section covers frequently asked questions (FAQ) about breast implant placement. Implant placement refers to how deep in your chest the breast implants are implanted. They can be placed just under the breast tissue (subglandularly or over) or partially under the pectoral muscle (subpectorally or under), or completely under the pectoralis major (and sometimes the serratus muscle as well). If you have a suggestion for any additional questions, please let us know.

Should I go over or under the muscle?
What is the difference between breast implants placed under the pectoralis muscle and implants placed under it?
When is it important to place the breast implants behind the muscle?
What are the disadvantages to placing the breast implant behind the muscle?
Can I have breast implants placed behind the muscle with a transumbilical insertion?
Can I work out my chest muscles if I have unders?
Can I go without a bra now that I unders?
Do unders feel weird?
Do unders give support like an internal bra? What about full unders?
Is the rate of capsular contracture higher with overs than with unders?
Can I change from unders to overs and vice versa if I am not happy with my placement?
My doctor only does unders (or overs), what should I do?
Is it true symmastia and displacement can be common in active people with unders?
Does subpectoral placement cause muscle atrophy?
How long does it take for breast implants to drop with unders?
Do breast implants placed over the muscle drop faster than those placed under?
I know I need a breast lift, but do not want the scars. Is it okay to get unders without a lift?
Should I get smooth or textured breast implants if I get overs/unders?
Do I have to massage if I get unders?
Do I have to massage with textured breast implants?
Which breast implant placement helps hide rippling?
Is breast cancer easier to detect with unders rather than overs?
Do breast implants rupture more often with unders than with overs?

1. Should I go over or under the muscle?

You’ll have to decide that yourself. It entirely depends upon your needs and your desires. There are advantages and disadvantages to having the implant below the breast tissue only and having it below the breast and chest muscles. Choosing your placement should be a decision based on consultations one or more surgeons and on your own needs. If you have very small breasts and relatively thin skin, you may need to go under. Although some surgeons may prefer one type of placement, if you have adequate tissue and average skin thickness, breast implants over the muscle should not be a problem.

2. What is the difference between breast implants placed over the pectoralis muscle and implants placed under it?

The primary difference between breast implant placement over of the muscle and under the muscle is the type of look that the breasts will have. Over the muscle, the top edge of the implant can show and have a distinct cleavage line that extends up around the top of the breast. Under the muscle, the upper edge of the implant is not as distinct. The degree to which the placement affects the final result depends upon several factors.

In general, breast implant placement makes more of a difference when you are making a big change in size. However, the heavier and larger breasted a woman is to start, the less the impact of the different placements.

The first diagram shows a natural breast. The second shows a subglandular placement, with the implant under the breast only. The third shows a subpectoral placement, with the implant under the pectoral muscle. The breast implant placement can be behind the pectoralis muscle alone, which is sometimes called a partial under placement (or partials unders). The pectoralis covers the top two-thirds or so of the implant with partial unders.

Sometimes you hear about a full under placement that involves placing the breast implant below the pectoralis and another chest muscle, the serratus muscle, and, occasionally, under a section of the rectus abdominalis muscle as well. All surgeons do not offer a full under placement.

3. When is it important to place the breast implants behind the muscle?

Often, in a woman who has an A cup or smaller preoperatively, the muscle may be needed to help cover the breast implant. Also, when a woman wants to go to a large size (full D cup or larger) and has thin skin and little subcutaneous tissue, the muscle is needed to cover the implant. One problem with having too little breast tissue is rippling or contour irregularities in the implant. Even with an under placement, rippling can occur on the sides or bottom of the breast.

4. What are the disadvantages to placing the breast implant behind the muscle?

The disadvantages are less cleavage, less natural breast movement, movement of the breast when the pectoralis muscle is contracted, longer recovery with more initial discomfort, and a slightly firmer feel

5. Can I have breast implants placed behind the muscle with a transumbilical insertion?

Yes, you can have breast implants placed partially underneath the pectoralis major muscle with the transumbilical technique.

6. Can I work out my chest muscles if I have unders?

Yes, you can work out your chest muscles with unders or full submuscular placement. You may notice that your breasts may twitch or jump when the muscles contract, but it is hardly noticeable by others.

7. Can I go without a bra now that I unders?

You can go without a bra with either placement at any time, but even unders need support. The longer and more often you go without a bra the more susceptible to sagging you are, no matter where your breast implant was placed The breast implant may be somewhat supported with under placement, but that doesn’t mean you can forgo your bras forever once you heal from your surgery.

8. Do unders feel weird?

It depends on how you define weird. It is only natural to notice a big difference between not having breast implants the day before surgery and then suddenly having them. You will get used to it no matter what placement you chose.

However, unders can feel different to the patient because of the movements of the pectoralis major. When you use your chest muscles, they contract around the upper part of the breast implant. This can feel like a pulling sensation and you can sometimes see this movement when naked or even under clothes. It is sort of like a body builder flexing their chest muscles. Some patients notice when they even use their chest muscles in every day movements, like picking up a heavy object. Don't think of it as weird. Think of it as a fact of life; get over it and start enjoying them!

9. Do unders give support like an internal bra? What about full unders?

This is not true with all patients. In standard subpectoral placement, only about the top two-thirds of the implant is covered by your pectoralis major muscle. The bottom of the implant is not supported by anything but your breast envelope. The breast implant can be somewhat supported with full submuscular placement.

Full submuscular placement is more of a way to help hide the implant in women with little or no breast tissue. It will provide some support, particularly for smaller implants Full submuscular placement was developed for breast reconstruction patients to help hide the implant edges since a mastectomy had removed their breasts completely.

Skin laxity is an issue in natural aging no matter what placement and going without a bra can significantly increase your chances of ptosis (sag).

10. Is the rate of capsular contracture higher with overs than with unders?

Some surgeons believe that the incidence of capsular contracture can be reduced if the breast implants are placed under the muscle. The idea is that the movement of the implant by the muscles helps prevent scar tissue from forming. However, capsular contracture happens in either placement, either silicone or saline breast implants, and with either smooth or textured surfaces.

11. Can I change from unders to overs and vice versa if I am not happy with my placement?

Yes, you are able to change at any time in a revision surgery. However, if you are switching from overs to unders, you will experience more discomfort than your previous surgery.

If you have had textured breast implants under for some time, removal of some muscle tissue may be necessary and it is possible that your muscles may not adhere back to the chest wall. If this happens you will notice an odd movement of the muscles after the revision, as though it was bunching up unnaturally.

12. My doctor only does unders (or overs), what should I do?

Ask your surgeon why he or she only offers one breast implant placement. You may need to get other opinions to see if that placement suits your specific needs. Both placements have pros and cons, so thoroughly research your options.

Some really great surgeons may only offer only one breast implant placement. Every surgeon will have his or her own preferences and reasons for them. Ask why, compare, and make your choice weighing all the factors that determine who is the right surgeon for you.

13. Is it true that symmastia and displacement can be common in active people with unders?

Symmastia is the term for when the two breast implants touch in the middle. More colloquially, it is called “uniboob.” Some surgeons believe that symmastia happens more often in patients with under placement. However, it can happen for several reasons, such as the breast implants being too large, too much muscle dissection (loosening) of the muscles at the breastbone while creating the pocket, displacement of the implants, and failure of the connective tissue. Just understand that symmastia is possible in any placement, not just one in particular. Ask your surgeon for more information on this subject.

Displacement, where the breast implants move out of position, can happen with unders. This can happen if you are active or sedentary as your pectoralis major is used very often through out your daily activities. It happens more with smooth implants, but then again, the most widely used implants are smooth, round ones.

14. Does subpectoral placement cause muscle atrophy?

Some surgeons believe that this is possible. However, there are many women with subpectoral breast implant placement who have no problems with muscle tone or function, so it may be exaggerated. It is a controversial issue and different surgeons have different opinions, so please ask your surgeon about the risk of muscle atrophy for you.

15. How long does it take for breast implants to drop with unders?

Your breast implants will drop slightly a few weeks to months after your surgery. Essentially, they drop into a more normal looking position. It takes time to heal and depending upon your breast implant surface and size and your muscle tone, the time your implant takes to drop can vary significantly. To get your breast implants to drop or to keep them up, if that is what you want, you may be asked to forcefully massage them, push them down, wear a wide strap around the top of your chest, wear no bra (or the opposite). Don’t worry if they are still high and hard by 6 months. This can happen.

If you still haven't dropped by 6 months (or have textured breast implants) a reoperation or firm massage may be needed. Please ask your surgeon about this because everyone is different. Smooth unders usually drop by the fourth month or so after surgery.

16. Do breast implants placed over the muscle drop faster than those placed under?

Usually, yes. There is no tense, traumatized muscle holding the breast implant to the chest with overs. Overs have just the breast envelope to hold them high and tight and as the skin stretches the implants will settle. This also depends on factors such as preoperative size, breast implant size, postoperative size, implant texture, and postoperative instructions. Your surgeon may advise you on whether or not to wear an underwire bra to control the drop.

17. I know I need a breast lift, but do not want the scars. Is it okay to get unders without a lift?

You might not like the results. If you need a breast lift and just get breast implants under the muscle, you may end up with a very unpleasing result called double bubble, where your implants produce one breast mound under the muscle and your natural breast tissue sags lower on the chest creates another breast mound. It can be described as having breasts higher up on the chest (created by the implants under the muscle), but nipple complexes and the natural breast lower on the chest. You end up with four breasts, not two. Not a good idea.

18. Should I get smooth or textured breast implants if I get overs/unders?

The choice up to you. If you are getting contoured breast implants, a textured surface is recommended so that the implant does not flip or rotate. Some surgeons prefer using textured silicone implants for unders and use smooth silicone implants for overs. Some prefer smooth salines in any placement, and of course, vice versa for all options. It is a surgeon preference and many times a surgeon usually sticks to one option that he feels he gets the best results with. Ask your surgeon for more information on his or her preferences.

19. Do I have to massage if I get unders?

Massage and compression—massaging and manual squeezing of the implant and breast—is another issue that a lot of breast augmentation surgeons disagree about. Many surgeons believe that massage helps ward off capsular contracture and just as many do not. Ask your surgeon about his or her beliefs about breast implant compression or massage.

Some surgeons believe that massage will help keep the roomy pocket open so that the breast implant movies around comfortably, naturally, and so that the implant pocket does not begin to squeeze the implant. Some believe that compression exercises help prevent capsular contracture.

Some surgeons believe that massage is necessary only with overs because the pectoral muscle massages the breast implant with your natural muscle contractions all the time.

However, contracture happens with both unders and overs, so you have to make the call.

20. Do I have to massage with textured breast implants?

Implant manufacturers originally developed textured breast implants with the belief that they would reduce the incidence of capsular contracture. Many surgeons agree that a textured surface makes no difference in the rate of capsular contracture and they report more difficulty in removing capsules from textured breast implants.

Moreover, many surgeons believe you should not massage textured implants placed under. Implant manufacturers may specifically recommend that you not massage or undergo a closed capsulotomy procedure regardless of the implant surface type. The say that this can cause the breast implant to fail and rupture.

Whatever the case, abide by your surgeon's instructions. If you do not follow your surgeon’s instructions, you may void any type of revision agreement, which will put the majority of reoperation expenses in your court.

21. Which breast implant placement helps hide rippling?

Rippling is the occurrence of palpable ridges, edges, wrinkles, or ripples of the breast implant under the skin. Some rippling is so pronounced you can see it clearly. Some rippling is only visible if you bend over or move a certain way or are in a certain position. Regardless, it is unattractive and a telltale sign of implants.

Using the optimal fill amount for saline breast implants can lessen rippling, but even so, it can happen. Placing the implants subpectorally (under) can lessen the appearance of rippling in the cleavage area, top and on the upper outside areas of the implant. However, since the pectoralis major only covers the upper two-thirds of the breast implant, rippling may be seen on the lower half in some patients.

Unfortunately, in thin and thin-skinned patients, rippling can really be visible. Some patients even choose to undergo full sub-muscular placement, which covers the implant in the lower areas of the breast as well. With full submuscular breast implant placement, the implant is placed through a transaxillary or periareolar incision and under the pectoralis, a section of the rectus abdominus fascia of the upper abdomen, and the serratus muscles. All surgeons do not offer this placement.

22. Is breast cancer easier to detect with unders rather than overs?

Breast implants can interfere with early detection of breast cancer, but mammography is still important. With unders, the muscle only covers the top two thirds of the implant and even less for larger sizes.

There are mammography techniques (specifically the Eklund technique) that should be used when you have mammograms taken. You also will need to have additional films taken, which will significantly increase your chances of detection.

Please read more on this subject in the Mammograms and More Section.

23. Do breast implants rupture more often with unders than with overs?

There are conflicting reports on this. Some surgeons believe that overs may deflate more due to increased capsular contracture rates, or no protection by the muscle. Some believe the opposite and say that the rate of rupture is higher due to muscle contractions. There are also many variables in breast implant rupture, including implant type, implant surface, optimal fill volume, physical activity, surgeon, filler, etc., that combined may alter your chances of implant rupture. This is yet another question to ask your own surgeon to find out his own personal percentages/experience with rupture.