Breast implants: over versus under the muscle?

The left implant is a saline implant which is deflated. The right implant is a silicone implant.

When breast implants were first invented, silicone fill was always used. During this era, the implants were placed over the muscle. Later, saline implants were developed, but they never felt as natural and they tended to ripple (or scallop along the edges). It was around this time that someone started putting the implants under the muscle, so there would be more body tissue between the implant and the outside, hopefully to make the look and feel of the enlarged breast more natural. The standard practice now is to place just the top part of the implant under the muscle and the lower part of the implant under just the breast tissue and skin. The lowest 20 per cent of the muscle is cut, in order to allow this.

Remember that for a time, there was thinking by regulators in the USA that silicone implants were dangerous, and they were banned from general use for about a decade. Sub-muscular implant placement really gained popularity during this period for the saline implants that were used.

Now, there’s a third way to place the implant, and that’s under the “skin” or “fascia” of the muscle, above the muscle and below the breast tissue. This has some of the advantages of both approaches. This technique has been popularized by one of the busiest breast surgeons in the USA: Dan Metcalf, MD, who frequently performs over 600 breast implant cases a year. Most sub fascial implants are performed through an armpit incision, where the "skin" of the muscle is thick and easily identifiable by the surgeon. Many of these implants were placed as described.

There are surgeons who have been trained that only sub-muscular implants are right and there are surgeons who mostly do sub-glandular (above the muscle) implants and others who believe that sub-muscular implants lead to lots of problems ten years after surgery. Do not believe anyone who tells you that there’s one best way to do this surgery for every patient. Here are some photos of breast implants placed under the muscle.

What does Dr. Yoho do for his Pasadena / Fresno / Visalia cosmetic surgery breast patients? We individualize the approach for each person. The questions we ask are: what do their breasts look like, can they afford and do they want silicone implants, and what sort of incision is desired. For patients who have relatively perky well formed breasts with normal shape and lots of breast tissue, they may get very nice results with a sub-fascial or above the muscle approach with a saline implant and have just as good a result as with a silicone implant. For patients who have odd breasts, such as “tubular” breasts, often a silicone implant above the muscle is recommended because of the surgery needed and the skin stretching that may be needed. If you have very little breast tissue, you likely are a better candidate for sub-muscular implants. These can be silicone or saline depending on the preference. See DrYoho.com for more on silicone versus saline and the style of implants available. We absolutely have to have a look at your breasts and speak to you about your individual preferences to give you the best idea of what is right for you.