Richard V. Dowden, M.D., C.M., F.A.C.S.

Certified by the American Board of Plastic Surgery

Cosmetic and Plastic Surgery, Inc.
6770 Mayfield Road, Suite 410
(Mayfield Heights) Cleveland, Ohio 44124
(440) 449-7470

Answers to Frequently Asked Questions about
breast enlargement through-the-navel ( TUBA ):

What is the difference between implants in-front-of vs behind the pectoral muscle?

The 'Under' vs 'Over' question is almost as confusing as the question of overfill of implants. So hang on for some complex information!

The primary difference between in-front-of-the-muscle ('Over'), and behind-the-muscle ('Under') placement of the implant is the type of "look" that the breasts have. In front of the muscle, the implant has more definition up over the top of the breast. With behind-the-muscle implants, the definition on top is less distinct. However, if there is hardening in a thin person, there can be a lot of definition with either 'Unders' or 'Overs'! The degree to which the placement in front of or behind the muscle affects the final appearance always depends upon:

It is important to be aware of the fact that in an 'Under' implant there is covering pectoral muscle only in the part that is upper and more toward the cleavage. Why is that all? Because the way the pectoral muscle is anatomically shaped, there simply is none of it at the bottom or outside edge of the breast. Look in a mirror, at your left breast, and picture on it a clock face, with 9:00 near your arm and 3:00 near the other breast. As you see it in the mirror, picture a line drawn from 10:00 near the underarm down to about 6:00 at the bottom. The pectoral muscle is present on the side of that line that is closest to your other breast; there is no pectoral muscle at all to the side of that line that is toward the arm, and so even an 'Under' implant is actually an 'Over' in that area. In addition, there is a narrow strip along the bottom, from 6:00 over to about 4:00, where the surgeon releases the muscle from the ribs to prevent it pushing the implant up abnormally, and there too an 'Under' is actually 'Over'.

Tastes vary from person to person. Of my patients requesting breast augmentation, more than half (60%) are requesting the in-front-of-the-muscle look, and less than half (40%) want the behind-the-muscle look.

Characteristics of in-front-of-the-muscle ('Overs') implants:

Characteristics of behind-the-muscle ('Unders') implants:

But, some women with "Unders" can look as though they have "Overs", and some women with "Overs" can look as though they have "Unders". This is individually decided with each woman, and is explained in detail at her consultation. None of the above is a really major factor, but they are important to some women.

Other considerations with differences of opinion:

Hardening:
The chance of needing surgery for hardening (capsular contracture) is the same for women with over-the-muscle implants as for those with under-the-muscle implants, BUT the over-the-muscle implant patients must do daily compression exercises (massage) to achieve this low level. Some surgeons do not have their patients do these massage exercises, so therefore they will only place implants under the muscle, telling them that they will have a lower chance of hardening. Incidentally there is a growing body of opinion that the through-the-navel ('TUBA') method has a lower chance of hardening. There are theoretical explanations for this, but there has not yet been a scientifically valid study reported to prove it.

Cancer protection:
Some surgeons believe that placement of implants in front of the muscle ('Overs') may be beneficial if a breast cancer ever develops. The rationale for this speculation is that the implant would supposedly block the cancer from reaching the muscle and its rich network of blood vessels and lymph ducts, and therefore might delay spreading of a cancer, whereas with 'Unders' this protection would be absent, just as for women without implants. This is absolutely pure speculation, and there is no scientifically valid evidence whatsoever for or against it in any way.

Mammograms:
There has never been any scientifically valid study showing that breast cancers have been missed or detected less early with 'Overs' than with 'Unders'. There is no evidence whatsoever that mammograms are better at detecting breast cancer with 'Unders' than with 'Overs'. However, some radiologists do say that it takes them longer to read an 'Over' mammogram than an 'Under' mammogram, so they prefer 'Unders'. Some theoretical calculations have suggested that there could be somewhat less apparent cross-sectional breast tissue with 'Overs' than there is with 'Unders', but in fact there is absolutely no evidence that cancers are more detectable with 'Unders' than with 'Overs'.

Breast support:
Some people believe that with 'Unders' the muscle will support to the breast through the years. Both kinds of placement, Under or Over the muscle, do lift the breasts by increasing the contained volume within the skin envelope, 'Overs' more so than 'Unders'. But that is not 'support', rather it is initial lifting. the muscle does not reach all the way down to the bottom part of the breast, so 'support' of the implant does not come from the muscle. Support comes from the scar capsule around the implant. The important factors are whether there is hardening of the scar capsule, and whether the back of the capsule is attached to the ribs or to the muscle.

If the scar capsule is large and not contracted, the implant will be free to move within its pocket, whether the implant is 'Over' or 'Under' the muscle. But if the scar capsule is contracted and hard, then the implant will be held to whatever is behind it; in that case, an 'Under' implant is held to the ribs, whereas an 'Over' implant is held to the front of the muscle in its upper portion. As the breast tissue and skin relax over time, the breast itself will relax downward, no matter where the implant is placed. If there is no contracture, the breast can continue to look good with both 'Overs' and 'Unders'. But if there is hardening of the capsule, the degree to which the implant can stay with the relaxing breast over the years is different for Overs than Unders. And that is where 'Unders' can lead to a problem: if there is a fair amount of breast tissue, plus if there is considerable relaxation of the breast itself, plus if there is capsule contracture, then the implant cannot stay with the breast, and you get a so-called 'double-bubble' look, with the implant up, and the breast down. Obviously that happens less often with 'Overs' for the reasons explained above.

Wrinkling, rippling:
Some people think that there is less rippling with 'Unders' than with 'Overs', but actually there is rarely any difference, provided the implant is properly filled to its optimum. With a properly-filled implant, the only rippling is at the sides and bottom - locations where there is no muscle, so it makes no difference Over or Under the muscle. There is muscle behind the upper part of the breast, but if the implant is properly filled then that is not where rippling occurs. If the implant is properly filled, there is no wrinkling of the upper part, and so 'Over' or 'Under' make no difference. But if the surgeon has decided NOT to fill the implant to its optimum volume, then 'Unders' would be better. For an extremely thin woman who has virtually no breast tissue to start with, there are other considerations that will be discussed at consultation.

Confusing? You bet! There are desirable characteristics inherent in both 'Unders' and 'Overs'. Personally, I do both 'Overs' and 'Unders', and currently it is running about 55% 'Overs' and 45% 'Unders'. That decision I personalize for each woman, and next to size choice, it is the next most important of the many decisions that are made during consultation. You may have noticed (and wondered why) that different surgeons seem to have conflicting opinions about the different aspects of breast augmentation surgery. It is no wonder a proper consultation takes at least four hours!


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6770 Mayfield Road, Suite 410
(Mayfield Heights) Cleveland, Ohio 44124
(440) 449-7470

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Last Update: 7:27 PM on 02/03/2008
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