The Over/Under Debate

Published on March 1, 2015

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Implant size: Larger or smaller? Incision location?

One of the most commonly debated choices is that of implants placement: subglandular vs. submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation:

  • Subglandular augmentation means placing the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain. Recovery is also faster when compared to subpectoral augmentation.
  • Subglandular augmentation can make mammographic evaluation of the breast more difficult. It is important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRIs (the most sensitive and specific study available for breast cancer detection).
  • Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.
  • Aesthetically, implants placed above the muscle creates a more rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.


Subpectoral Augmentation:

  • In sub pectoral augmentation, the lower border of the pectoralis major muscle is released and the upper hemisphere of the implant sits underneath the muscle. The release of the muscle contributes to the discomfort encountered postoperatively by patients.
  • Subpectoral implants have a lower rate of capsular contracture (hardening of the breast).
  • Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a more natural tear drop shape.


Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other. As always, your board certified plastic surgeon can help guide you in your decision making process. Dr. Glassman can help you determine which technique is best for you. Call us at 845-354-7878.


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