Breast Implants: Under or Over the muscle, what is the best?

The short answer to this question is that it depends ... what follows are some of the factors that go in to making an informed decision as to whether the breast implant should be placed over or under the muscle.  For starters, the muscle being discussed if the pectoralis major muscle; put yours hands together and press and that is the muscle we are talking about (it is the same muscle used for planking or push ups).  If you decide upon a saline implant, the recommendation is to place the saline implant under the muscle the vast majority of the time.  Because the saline implant is easier to detect by sight and feel and the muscle offers additional coverage of the upper half or two thirds of the implant, saline implants are generally placed under the muscle.  Gel implants, because they are harder to detect, can go over or under the muscle.  With enough breast tissue of your own, for example about 2 centimeters thickness when pinching, the implant will be hard to detect.  So the question arrises, why go above the muscle?  There are several advantages to going above the muscle; less pain, quicker recovery, a tendency to a more natural appearing result, an absence of implant distortion with muscle contraction in the short term and implant bottoming out in the long term.  Placement above the muscle does have its cons though; increased chance of seeing ripples and the possible need for additional imaging during mammography.  See the table below for a quick reference...

Above muscle

Below muscle

more risk of ripples less risk of ripples
less pain more pain
less recovery more recovery
implant does not move with muscle contraction implant moves with muscle contraction 
less risk of bottoming out more risk of bottoming out
tends to more natural appearance tends to less natural appearance
may need more views on mammogram lees effect on mammogram
tendency to narrower cleavage tendency to wider cleavage

The bottom line is that for the best recommendation seek consultation with a board certified plastic surgeon who can go over all of these aspects detail and help you make the best decision for your individual situation.

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