Breast Implants: Under vs Over Muscle

Breast Reduction Perth

Why I do not place breast implants under the muscle!

In 2021, the federal and state governments launched a review of the cosmetic surgery industry. There was particular focus around laws into who can call themselves cosmetic surgeons.

In light of this review, and to help people recognise the difference between a cosmetic surgeon and a specialist cosmetic surgeon, we updated this blog for those considering breast implant surgery in 2022.

One surgery practice that isn’t universal across the industry is the placement of breast implants, with some choosing to place implants under the pectoral muscle.

As a specialist surgeon, Dr Goldman explains why he DOES NOT place breast implants under the muscle. From breast development and the anatomy of the breast to muscle nerve supply and breast changes over time – there are many factors to consider.

Breast development and Anatomy

By placing breast implants behind the pectoral muscles the surgeon is failing to take into consideration the origin, development and structure of the (female) breast.

The breast is a modified skin gland. It has its origins in a layer called the “ectoderm” this is one of the 3 primary layers that the developing human embryo develops from. It is the layer that forms all skin based structures including the breast, skin, sweat glands, hair, nails but to name some. The developing bodies muscle layer arises from the “mesoderm” or developing muscle layer. It is a separate structural and functional body layer.

Many surgeons both here in Australia as well as overseas perform submuscular breast augmentations. Unfortunately, the Thailand surgeons almost exclusively perform submuscular breast augmentations.

The pectoral muscles of the chest have two components: the outer big pectoral muscles (pectoralis major) and the inner smaller (pectoralis minor). Submuscular breast implants are placed either behind the pectoralis major muscle or worse, behind both muscles. There is a variant of this technique what is called; “The Dual Plane” placement.

Disadvantages of submuscular breast augmentation

Some surgeons will use an incision in the armpit (axillary incision) while others will use an incision in the crease underneath the breast (infra-mammary). Either way, when a surgeon intends on performing a submuscular breast augmentation, a pocket must be created for the implant BEHIND the pectoral muscles. If the surgeon is using an infra-mammary incision, the lowermost attachment of the pectoral muscles to the ribs must be cut to enter the natural tissue plane under the muscles.

The muscle is then lifted off the ribs to create the pocket. If the surgeon uses the armpit approach, the lowermost attachment of the muscles are left undisturbed but the implants will sit too high on the chest as the breast implants are “pushed up” by the strong attachment of the pectoral muscles as well as the ligaments of the infra-mammary crease.

Running out of the chest, from between the rib space, are the two nerves that supply the pectoral muscles, called the medial and lateral pectoral nerves. These are either stretched as they are moved sideways to accommodate the implant or worse, these two nerves are even cut as part of the pocket creation.

This together with the need to cut the lowermost attachment of the muscle itself results in a process called atrophy. This means thinning, weakening and wasting of the pectoralis major muscle. Women may often notice this effect as a degree of upper body weakness.

Now, the pectoral major muscle also has an attachment to the collar bone at the top and the edge/side of the breastbone (sternum). The anatomy of this muscle has more significant effects on the result and outcome of breast enhancement /augmentation.

A pocket for breast implants behind the muscles lifts up this muscle and because it has its uppermost attachment to the collarbone, the “breast” looks too high on the chest. Next, as the pocket is behind the muscle and this then is attached to the side of the breastbone, the breasts look “too wide apart” this results in an undesirable and un-natural looking cleavage.

On occasion, with the incision underneath the breast and a submuscular implant placement, the bottom cut edge of the muscle can become visible. On contracting the pectoral muscles, the contraction pulls the implants and the breast up and outwards.

All these issues are very far from natural and the appearance and functionality of the breast are very unnatural. Despite all of this, the single and most important reason why submuscular breast augmentations are not the natural and desired procedure, is that all women’s breasts will, over time, droop off the implants as the implants are held in a fixed and unmovable position by the pectoral muscles. It is essential that the implant is part of the breast, moves and behaves exactly as the breast does, an impossibility with submuscular breast augmentations.

Lastly and specifically related to the surgery, the overall risks and complications are greater, the re-operation rate (need for corrective surgery) is almost universal and finally, the postoperative pain levels with a muscle-cutting operation are severe necessitating possibly up to 5 days of bed rest, very strong analgesics (pain killers) and a prolonged downtime.

Advantages of submuscular breast augmentation

Almost none! However, the under the muscle operation was developed some 30 or more years ago when the quality of breast implants was very poor compared to the high quality, soft, natural feeling breast implants used today.

With the older style breast implants, particularly in petite, flat chested women, it was far more natural to place these implants behind the pectoral muscles so that the breast implant could not be seen or felt. With today’s modern, soft, very naturally feeling breast implants, this is no longer the case.

The anatomical, developmental and functional aspects of the breast as discussed above form the basis of why Dr Robert Goldman almost never will perform a submuscular Augmentation Mammoplasty (breast augmentation).

Need more information regarding breast implants, augmentations or reductions? Contact Dr Robert Goldman for a discussion of your needs and circumstances.


Are You Considering Cosmetic Surgery?

Download our Cosmetic Surgery Information Pack

Choose your Information Pack(Required)
Request a Call Back