Implant Placement: Above or Below the Muscle? Navigating Your Breast Reconstruction Options

When undergoing breast reconstruction after a mastectomy, one of the most significant decisions you’ll make with your surgeon is where to place the implant—above or below the chest muscle.

Both options have their advantages and drawbacks, but in many cases, especially after mastectomy, placing the implant above the muscle (prepectoral) often yields more natural-looking and comfortable results.

Let’s dive into why this choice is critical and what factors to consider when making your decision.

Why Implant Placement Matters

The positioning of the implant—whether it’s above the pectoral muscle (prepectoral) or below it (subpectoral)—impacts various aspects of breast reconstruction, including recovery time, long-term aesthetics, and overall comfort.

For patients who have had a mastectomy, especially those who have lost all their breast tissue, the traditional submuscular (under the muscle) approach can create an unnatural appearance. In such cases, there is little to no natural tissue left to provide a smooth transition over the implant, which can result in an overly “stuck” look, with the implant being compressed behind the muscle.

Conversely, placing the implant above the muscle creates a more natural breast contour. This is particularly beneficial for patients undergoing post-mastectomy reconstruction, as the implant can better mimic the natural sag and movement of a breast.

Above the Muscle (Prepectoral) Implant Placement

In prepectoral implant placement, the surgeon places the implant directly on top of the chest muscle, within the existing skin envelope, and sometimes uses an acellular dermal matrix (ADM) or similar material to support and secure the implant.

Advantages of Above-the-Muscle Placement:

More Natural Appearance Over Time: One of the main benefits of placing implants above the muscle is that they age more naturally. As you get older, breasts naturally droop or sag slightly, and implants in a prepectoral position mimic this behavior. This results in a softer, more natural look over time.
Less Painful Recovery: Since the chest muscles are left intact, patients experience less post-operative pain and a faster recovery than submuscular placement, where the muscle has to be cut and manipulated to make room for the implant. This is a significant benefit for many patients, especially after a physically taxing procedure like a mastectomy.
Better Aesthetic for Mastectomy Patients: In cases where a mastectomy has removed all breast tissue, placing the implant below the muscle can lead to a hollow or overly tight appearance, especially for thinner women. With prepectoral placement, the implant fills out the breast area more naturally and doesn’t suffer from muscle compression that can sometimes distort the implant’s shape.
No Animation Deformity: One major downside of submuscular implants is that they can shift or “animate” when the pectoral muscles are engaged, such as during exercise or arm movement. This distortion, or animation deformity, does not occur when the implant is placed above the muscle.

Potential Drawbacks of Above-the-Muscle Placement:

Less Soft Tissue Coverage: One concern with prepectoral placement is that there is less soft tissue covering the implant. For women with thin skin or minimal natural breast tissue, this can sometimes result in visible rippling or wrinkling of the implant, although techniques like using ADMs or fat transfer can mitigate this issue.
Capsular Contracture Risk: There is a slightly higher risk of capsular contracture—a condition where scar tissue tightens around the implant, potentially causing discomfort and altering the appearance of the breast. However, the incidence is not dramatically higher and is often manageable with modern surgical techniques.

Below the Muscle (Submuscular) Implant Placement

In submuscular implant placement, the surgeon creates a pocket under the pectoralis major muscle to house the implant. This method has been widely used for breast reconstruction and augmentation, but it may not always be the best choice, particularly for post-mastectomy patients.

Advantages of Below-the-Muscle Placement:

More Tissue Coverage: For women who still have some breast tissue or are very thin, placing the implant under the muscle can provide additional coverage. This reduces the visibility of the implant and the risk of rippling.
Lower Capsular Contracture Rates: Submuscular placement is often associated with a slightly lower risk of capsular contracture, as the implant is further away from the skin and the tissue that typically forms the scar tissue capsule.

Disadvantages of Below-the-Muscle Placement:

Painful Recovery: Since the pectoral muscle is cut and manipulated during this procedure, the recovery can be longer and more painful than prepectoral placement. Patients may experience more discomfort, tightness, and a prolonged healing process.
Unnatural Look for Mastectomy Patients: For women who have undergone a mastectomy and lost most or all of their natural breast tissue, placing the implant under the muscle often results in a less natural look. Without tissue above the implant, the result can appear overly tight or “stuck” to the chest.
Animation Deformity: As mentioned earlier, submuscular implants can move unnaturally when the chest muscles are flexed, which may be particularly problematic for active women who frequently use their upper body muscles.

Why Your Surgeon Might Recommend Above-the-Muscle Placement

For many patients, especially those undergoing post-mastectomy reconstruction, the above-the-muscle (prepectoral) approach offers a more natural and comfortable result. The surgery is less invasive, recovery is quicker, and the final aesthetic can be more in line with the natural movement and aging of a breast. Moreover, this approach avoids complications like animation deformity and can be ideal for patients with thin skin or little natural breast tissue.

If your doctor mostly recommends above-the-muscle placement, it’s likely because they have seen better outcomes for their patients, especially after mastectomy, where there is no remaining tissue to cover the implant. This placement allows for a more natural look and feel while also making recovery easier and less painful.

Which Option is Right for You?

Ultimately, the decision to place implants above or below the muscle should be made in consultation with your surgeon. Factors like your body type, the amount of natural breast tissue, lifestyle, and aesthetic goals all play a role in determining which option is best suited for your reconstruction.

Above-the-muscle placement may provide a more natural, comfortable result for many patients, especially those undergoing reconstruction after mastectomy. On the other hand, submuscular placement may still be a good option for those who need extra tissue coverage or want to minimize the risk of capsular contracture. Discuss all your options with your surgeon to ensure you make the choice that aligns with your needs and goals.

Schedule your consultation today at My Breast Cancer Doc to discuss your options. Call us at 470-322-6757 to book your appointment.