What are the pros and cons of breast implant placement under the muscle compared with on top of the muscle?

Question:

What are the pros and cons of breast implant placement under the muscle compared with on top of the muscle?

Answer:

Breast implant positioning with augmentation surgery can be described as a subglandular position, which is on top of the muscle and beneath the glandular tissue of the breast, or a subpectoral position, which is under both the glandular tissue and the pectoralis major muscle. An alternative is what is described as submuscular positioning where the implant is positioned beneath the pectoralis major muscle as well as beneath a second muscle called the serratus anterior muscle.

The main benefit of placing a breast implant beneath the pectoralis major muscle is to provide greater soft tissue coverage of the implant. This primarily is performed to minimize the risk of the complication of capsular contracture and this effect is well documented in the medical literature. Another benefit of this positioning of implants is to decrease the risk of visible rippling or wrinkling of the implant. The implant not only may be less visible but may also be less palpable, particularly in the upper pole in the area of the pectoralis major muscle. Additionally, this implant placement can lead to greater fullness in the upper pole of the breast, which results in, at times, an augmented appearance to the breast with convexity of the upper pole. Subpectoral or submuscular position of implants generally results in slightly higher positioning of the implants on the chest wall.

Subglandular positioning of the breast implants on top of the pectoralis major muscle and beneath the glandular tissue, although being less protective against capsular contracture and resulting in a higher likelihood of visible rippling and wrinkling, has other potential benefits. The possible benefits include lower positioning of the implant on the chest wall, which may result in a slight lifting effect, or upward rotation of the nipple, which may be desirable in a case where there is some ptosis or sagging of the breast. Subglandular positioning of implants results in less dramatic upper pole fullness and a more natural appearing result, with a less obviously augmented look. Additionally, placing implants in a subglandular position should be less painful than subpectoral or submuscular positioning.

In general, patients with smaller breasts with little or no ptosis or sagging are more likely to have implants placed in a subpectoral position. Patients with larger breasts and possibly with some ptosis or sagging are more likely to have implants positioned in a subglandular position for augmentation.