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Position of breast implants
above or below the pectoral muscle?

During a consultation for breast enhancement one of the first decisions a patient and her surgeon must make is where to place the implant. There are two choices: below the gland of the breast and above the pectoral muscle, or below the pectoral muscle. Neither approach is perfect and the needs of each patient must be considered on an individual basis.

The pectoral muscle is a large almost triangular muscle which sweeps across the chest with one point at the shoulder and one side attached to the chest bone.

The original method of surgery was to place the implant beneath the gland of the breast and above the muscle. This worked well for most patients who got a good cosmetic result. However a significant number of patients, perhaps as high as one in four, developed hardening of the layer of scar tissue around the implant.

Surgeons were on the look out for ways to reduce the number of patients who developed hardening or contracture of the capsule. During the 1970s surgeons began to reconstruct the breast after cancer. In these patients there was no breast tissue and so the implant was always placed beneath the muscle. Experience with this operation and in other areas showed that placing the implant beneath the pectoral muscle significantly reduced the risk of hardening of the capsule. Many surgeons began to routinely place the implant beneath the muscle in all patients.

As time passed, the submuscular position was also found to have problems of its own. There is a change in shape of the breast whenever the pectoral muscle contracts, for example when working out. Another problem is that the implant always remains high because of the support of the muscle, but any existing breast tissue begins to droop as the patient grow older. The result may be a bilobed or "snoopy" breast.

During the 1980s textured implants, with a rough surface, were introduced. Many surgeons feel that these reduce the risk of hardening sufficiently for them to place the implant above the pectoral muscle and not have the disadvantage of the submuscular approach. In addition saline filled implants, which are the only type of implant available in the United States at this time seem to be less likely to cause hard capsule formation.

Many other factors need to be considered when deciding on the position of the implant these include: the size of the implant, the possibility of wrinkling of the implant and the patient's choice of incision.

In the past it was felt that placing the implant under the muscle eliminated the risk of wrinkling. This is not true and many patients with implants placed under the muscle still experience wrinkling.

Ultimately the choice of implant position must be tailored to the patient's needs. Each surgeon will have a different experience and develops a technique with which he or she gets their best results. There are no fixed rules or clear cut answers when it comes to implant position. However if you already have laxity of breast skin (breast ptosis), a "B" cup or larger, or you like to lift weights, then placing the implant below the muscle may not be for you. As always, your best decision is made in consultation with your own board certified plastic surgeon.