Breast Augmentation, Over or Under the Muscle?
Conveniently located to serve the areas of Maryland, Virginia and Washington, D.C.
Posted on November 5, 2025 under Breast Augmentation
I see patients every week who desire breast augmentation and have questions about the right “plane” to place the implant in.
Anatomically, the layers between the chest skin and the skeleton are comprised of skin, breast tissue, and fat, and then the underlying pectoral muscles, and the skeleton. Basically, the implant can go completely under the pectoralis major muscle, partially under it, or completely on top. Let’s look at each of these options, and I will share my 35 years of experience in helping you decide which is best.
The easiest plane to place the implant is under the breast tissue and fat and over the pectoralis muscles. The plane is relatively easy to dissect and causes little post operative pain. The implant, when placed, looks very good except in very thin patients. The implants tend to settle quickly and for the first year or so, people are happy. The problem is that you have disrupted “Cooper’s ligaments,” which serve to attach the breast tissue to the underlying chest wall. Now, with the weight of the implants, there is little to stop the skin from stretching and for the breast to sag. This is especially true for large implants. In addition, there is a slightly higher rate of capsular contracture with this approach.
Another option is to place the implants completely under the muscle. This was a common breast reconstruction technique after a mastectomy to ensure implant coverage after a mastectomy. The implants seldom become firm using this approach, but the implants are too high, especially when using large implants. This approach does offer the advantage of providing upper pole fullness in the breast, but over time, the breast tissue sags slightly and the upper pole stays high. This leads to the breast appearing to fall off the mound. Also, there is excessive movement on chest flexion that can be noticeable. I see patients who have had this approach and have to open the lower pole of the pocket to fix it.
The last approach is going under the pectoralis muscle but releasing (cutting) the inferior attachment under the breast. When this is done, the implant sits over the pectoral minor muscle and under the pectoralis major muscle and the inferior breast tissue. I find this to be an ideal plane for a long lasting, natural, attractive looking breast. The lower pole (the area from the nipple to the inframammary crease may initially be tight but this slowly stretches to give the nice, rounded appearance on the bottom portion of the breast that so many women seek. Also, because the muscle is intact above and Cooper’s ligaments have not been cut, the appearance is not only natural but long lasting. I see women in their 60s and 70s with attractive breasts years after a sub-muscular augmentation.
I hope this helps you understand your options. Please contact the office if you have further questions.
All the Best,
Dr. J
