When you’re thinking about cosmetic breast augmentation, you have many choices, including size and shape of the implants, saline or silicone implants, incision options and the placement of the breast implant either above or below the muscle.
The choice of having the breast implants placed in a subglandular (above the muscle) location or in a submuscular (beneath the muscle) location is something that many women are concerned about. Although it is generally wise to follow the recommendations of your plastic surgeon, it is helpful to understand some of the reasons for selecting one location or the other.
In the eyes of most women, the prettiest breast augmentation is one in which the breasts do not look obviously augmented, but instead appear naturally larger. If the edge of the implant or its contour is visible, the appearance of the breast is less natural. Conversely, if you cannot see the outlines of the implant, then the breast tends to appear naturally larger without the “augmented” look.
This is easiest to accomplish when the implant is well covered by an adequate padding of tissue. The thinner the tissues over the implant, the more it looks like an implant is present. For example, a basketball covered with a sheet, looks just like a basketball covered with a sheet. But a tennis ball covered by a comforter will just look like a bump in the comforter. The more cushioning between the implant and the skin, the less it looks like an implant.
One way to increase the padding over the implant and camouflage its presence is to place the implant “under the muscle.” The muscle referred to here is the pectoralis major muscle. This is the muscle on the chest that body builders develop and the muscle used to do push-ups. When the breast implant is placed under this muscle, it will cover the upper portion of the implant and the portion closest to the breast bone. This is the area most commonly exposed in swimwear and V-neck sweaters.
It is not necessary, however, that all women have their breast implants placed submuscularly. Many women have enough natural breast tissue so that placing the implants under the muscle offers no additional cosmetic benefit. This is especially true when using silicone implants. Further, there is some additional discomfort in the first few days after surgery with a submuscular augmentation.
Silicone implants are softer than saline implants and tend not to be as visible as saline implants. Furthermore, silicone implants tend not to ripple. Rippling occurs when the surface of the implant develops waves in it and these ripples are visible on the surface of the breast. Rippling is a common problem for saline implants; so much so that I rarely place saline implants over the muscle in a subglandular location. Rippling is rarely visible with an under the muscle breast augmentation.
An additional benefit to a submuscular breast augmentation is that the tendency for the development of capsular contracture with the implants placed under the muscle is less. Although the risk of capsular contracture is small and having the implants under the muscle decreases the risk by only few percentage points, sometimes placing the implants under the muscle to minimize the risk of capsular contracture may be important. This is especially true in cases of recurrent capsular contracture.
In the end, it generally best to follow the recommendations of your plastic surgeon. Your surgeon wants you to get the best result possible and will make recommendations based on their experience and your body/breast characteristics.