Why do submuscular breast augmentation?
Breast augmentations involve placing a breast implant into the chest. This can be done IN FRONT of the pectoralis major muscle, which is also known as “subglandular,” or it can be placed BEHIND the pectoralis major muscle, known as “submuscular.” The breast naturally sits in front of the muscle. So why release the muscle?
This started when saline implants came into play, as going behind the muscle gives more padding over the implant. I tell patients your tissue is like a comforter over the implant. Some of you have a thick comforter, so you won’t see or feel the implant as much. For others, their comforter is thin, think of a summer blanket or a sheet- they will see and feel everything. There are three big reasons to go behind the muscle.
- MORE COVERAGE. More tissue over the implant = better looking and feeling implant.
- LOWER CAPSULAR CONTRACTURE RATES. The muscle gives a great barrier between the bacteria laden breast and the new foreign object- your implant. It may also “massage” the capsule as it forms.
- EASIER MAMMOGRAMS. It is easier to see the breast tissue when the implants are behind the muscle. See my blogs. Mammograms with implants
How are breast implants placed currently under the muscle?
Currently most implants are placed under the muscle by releasing the inferior border of the muscle. How much your doctor does this varies. Some doctors will release it medially along the sternum as well. Some doctors release the pectoral part up higher, doing a “biplanar” approach. This is something to discuss with your doctor.
There has been a recent resurgence, particularly with Motiva implants, to put the implants under the breast gland or “subfascial,” which is the fascia overlying the pectoral muscle. I have thoughts on this- but too much to discuss in this blog.
A new technique. “Bimuscular Flap.”
This was in the latest Plastic and Reconstructive Surgery Journal. “A Modified Bimuscular Flap Technique for Breast Augmentation: Does Extra Muscle Support Enhance the Stability of Smooth Implants?” in the December 2025 issue. What this is getting at is that over time implants can have issues due to the thinness of the tissue, primarily RIPPLING and BOTTOMING OUT which is where the implant position migrates over time.
Study:
- 275 patients, avg BMI 18.5
- Findings: implant malposition 1%, bottoming out 0.2%, and rippling 3.2%
- They conclude, “ This technique balances muscle release and support, achieving satisfactory long term outcomes with lower rates of rippling, implant malposition, and bottoming out, making it preferable for very thin patients or those using large implants.”
Dr. Greenberg thoughts
I do a lot of breast augmentations, and many of these patients have thin cover. Part of that is why they are there- the have little breast tissue and fat, so their “comforter” of cover is thin. Add to that, over time, the weight of an implant will thin the tissue further.
I like this thought. It is simple- it involves releasing the pec major muscle with a vertical opening in the center, to allow a band of muscle to form a sling laterally. This supports the implant from migrating laterally, and it adds another layer of comforter where things tend to be particularly thin.
I also like this advocated for those who pick big implants (over 300cc?) as the strain of these implants on the tissue is more.
There are some patients this won’t be possible in (those with a constricted breast, where the muscle and breast itself end too high). And many women have very thin pectoral major muscles, so this may not do a ton of help. But the concept seems solid. I will research more.
Medical Citation
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