In my practice, I prefer to place breast implants ON TOP of the muscle, both for breast augmentation and breast reconstruction after mastectomy for breast cancer.

Why keep implants on top of the muscle?  Let me count the ways:

1. Implants placed on top of the muscle have a more natural look in most cases.
2. Placing implants on top of the muscle preserves the function and normal anatomyof the pectoralis major muscle.
3. Implants in the subglandular position or subcutaneous (“prepectoral”) location avoids the “animation deformity” or flexion deformity that occurs anytime the pec  muscle is flexed.  See an example here.
4. Recovery after breast augmentation in the subglandular position is much faster and much less painful than when the muscle is stretched out over an implant.
5. Breast reconstruction using implants on top of the muscle can be done in a single stage, and avoids the need for repeated injections of saline into a tissue expander that stretch the flat pectoralis major muscle tightly over the expander.  Doesn’t this just sound awful?  That’s what I thought, and is why I prefer immediate breast implant reconstruction in the subcutaneous plane.  Learn more about that here.
6. Not having implants under the muscle avoids several specific complications such as the “double bubble” defomity, “Snoopy or waterfall defomity” which only occur with submuscular implants.
7. It just makes sense to preserve the major chest muscle anatomy and function!

Anatomy of the chest wall. The pectoralis major muscle is a flat muscle with an upward and outward pull of its fibers. The pec muscle is used for nearly all upper body activities.

Compare the diagram of the chest muscle anatomy to this patient’s breast implant placement. It totally makes sense why the muscles pull the implants upwards and outwards, following the muscles’ vector of pull! I don’t know any woman who would want her breasts to do this.

Here is a video of a patient who is 6 months postop from a breast augmentation and lift (mastopexy).  Here she is showing her results with different arm positions – and most importantly – while flexing her muscles!

Her breasts look natural and she often forgets she has implants.  She just feels like herself!  Her breast scars will continue to fade over the next 6 months.

Good news – even if implants have been previously placed on top of the muscle for cosmetic or reconstructive surgery, a breast revision can put the muscles back down on the chest wall, reconstructing the normal anatomy of the chest muscles, and providing an improved aesthetic result. Learn more in this blog post.

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