Doctor Discourse: Should Implants be Placed Above or Below the Muscle?

Are you considering getting breast implants? If you are, then one of the biggest decisions you and your surgeon are going to have to make is whether to have the implants placed above the muscle (subglandular) or below the muscle (submuscular). Not sure what the differences are or which one is right for you? This article will help you understand the benefits of each and when they should be used so that you will be able to ask the right questions during consultation to help you get the results you want. sat down with two plastic surgeons to discuss the benefits of each placement. Dr. Brent Moelleken, Clinical Associate Professor at UCLA and Beverly Hills plastic surgeon agreed to speak with us about the benefits of submuscular placement, while Jefferey D. Wagner of Wagner and Associates in Indianapolis discusses the benefits with subglandular placement.

We asked each doctor the same seven questions to help you better understand the pros and cons of each option.

Tell me which implant placement you prefer in most cases and why?

Dr. Moelleken: Submuscular for two reasons:

  1. first because the scar contracture rate is lower
  2. and second because I think that aesthetically the implants are more natural.

Dr. Wagner: I think that the benefits of putting an implant in the subglandular location are several. First of all, I think the normal breast is in a subcutaneous location. Putting an implant in a subcutaneous or subglandular location more closely approximates the normal movement and, I think, motion of the breast. I look at it this way, a subglandular placement augments the breast, a submuscular implant is augmenting the chest wall, really.

What are the biggest advantages to this type of implant?

Dr. Moelleken: The biggest things are natural appearance, low complication rate, and low redo rate.

Dr. Wagner: There's probably about four of them.

  1. There's a better control of the breast shape first of all, because the pocket's easier to manage. You make it the size you want and it's right where you want to put it and you don't have to worry about it sliding around on the ribs and going into the axilla.
  2. There's also a more rapid recovery.
  3. You get increased control of the inframammary fold which is sort of the definition of the breast. You can change that, move it around, you don't disturb it when you're pulling up the pectoralis muscle.
  4. I think you don't get that distortion of the breast shape and abnormal movement of the breast with pectoralis contraction when it's underneath the breast.

What are the biggest disadvantages?

Dr. Moelleken: It is more difficult to place the implant below the muscle. Second, the chest configuration can change when a woman is moving or stretching.

Dr. Wagner: The downside of putting them on top of there is that in very thin patients you'll see an increased risk of visibility. I think the rippling of the implant might be more visible if you do it in a very thin patient. There might be an increased risk of capsular contracture, but I think that is debatable. If you do get capsular contracture, though, it's more likely to deform the breast and require reoperation. And there might be a little bit more difficulty with mammography with the implant on top of the muscle.

With this type of placement, name me all of the possible incision points and tell me which one you prefer and why?

Dr. Moelleken: Below the breast, around the areola, through the armpit and through the belly button. I prefer below the breast because it has the lowest chance of causing damage to the nipple.

Dr. Wagner: The transaxillary incision [through the armpit], the periareolar incision [around the nipple] and the inframammary crease [below the breast] incision. I like to use the inframammary incision the most. I think it's the most versatile incision, I think it doesn't divide any ducts around the nipple. [Though Dr. Wagner does not do incisions at the belly button in any instances, this is possible with subglandular implant placement]

What is the biggest complication or side effect possible with this type of placement that is not as prevalent in the other?

Dr. Moelleken: I don't think there is any. People will say that there is more bleeding or more pain, but I don't find that to be the case.

Dr. Wagner: I think that the most obvious thing, and I would emphasis that this can be avoided with proper patient selection, is an increased risk of the visibility of the edge of the implant or rippling.

In what cases would you use the other type of placement?

Dr. Moelleken: In cases where patients have droopy breast and do not want to have a breast lift along with implants. Also in competitive bodybuilders the very powerful chest muscle can push the implants out of position. Therefore it is sometimes preferable to place the implant above the muscle.

Dr. Wagner: I use submuscular placement preferably in several instances.

  1. if patients have a significant family history of breast carcinoma
  2. previous problem with capsular contracture
  3. patients are very thin
  4. and if patient really wants it.

I am going to name you a list of possible complications. Tell me if each one is more prevalent with subglandular placement, more prevalent with submuscular placement, or about the same.

  1. Symmastia
  2. Capsular contracture
  3. Bottoming out
  4. Deflation
  5. Double bubble
  6. Hematoma
  7. Seroma
  8. Rippling

Dr. Moelleken:

  1. Symmastia happens because the breast implants are too large. It is just bad decision on the part of the surgeon.
  2. This is higher in subglandular: almost double.
  3. I think probably sub-glandular but it is fairly similar
  4. Unknown. Probably similar, but you would think that this would happen more in subglandular because there is no protection but I have no numbers to back that up
  5. Underneath the muscle in droopy breast and double pole
  6. Same
  7. Same
  8. More common in subglandular because more of the implant is exposed

Dr. Wagner:

  1. probably about the same
  2. slightly higher with subglandular
  3. probably a slightly bigger problem with subglandular
  4. I don't think there's a difference
  5. A much bigger problem with submuscular
  6. Submuscular
  7. Submuscular
  8. Subglandular