The Makings of a Modern Boob Job

Jolene Edgar
·19 min read

With breast reductions, lifts, and implant removals on the rise—and the human form generally shrinking before our eyes, courtesy of Ozempic and Co.—one might question the status of the classic “boob job,” a procedure that unapologetically endows. Despite its inherent largesse and controversial nature, breast augmentation remains the most popular cosmetic surgery among women worldwide (and ranks number two in the U.S., with over 300,000 takers in 2023, according to the American Society of Plastic Surgeons). And the operation has evolved in recent years. The changes, breast specialists say, are largely driven by savvy patients, who are challenging old ideas about implants and advocating for the outcomes they want—right down to the surgical maneuvers used to achieve them.

Generating buzz across the internet is the reprisal of a decades-old technique that places implants on top of the chest muscle instead of under it, as has been customary for the past 20 years. (You may have seen surgeons on social talking about “subfascial” breast augmentation. This is usually what they’re referring to: tucking implants underneath the fascia, the connective tissue overlying the pectoralis muscle.) While there are benefits and drawbacks to both methods of augmentation, some surgeons are bucking below-the-muscle convention for a placement that, they believe, creates the most natural effect while ensuring the breasts move in a way that looks and feels normal.

That last part is crucial, but often overlooked, says board-certified Beverly Hills plastic surgeon Kelly Killeen, MD. In her experience, surgeons tend to focus too much on how results look in static photos while failing to consider that a breast which appears “natural” in an after picture may move unnaturally in real life. “As someone who had implants under the muscle, I can tell you, it feels weird, it’s not natural, and it makes a lot of women uncomfortable,” says Dr. Killeen. She started performing subfascial augmentations almost exclusively about two years ago, as more patients began requesting them, often after learning about the technique from surgeons and fellow patients on social media.

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Jerry Chidester, MD, a board-certified plastic surgeon in South Jordan, Utah, also switched to subfascial in response to patient complaints about how “foreign” it can feel to have implants under the muscle. “Some women have told me there’s like this mind-body dissociation,” he says. Others become hyper-aware of their implants when working out, picking up their kids, or otherwise engaging their pecs.

In addition to recounting similar stories of discomfort and exercise issues from patients with implants under the muscle, Troy Pittman, MD, a board-certified plastic surgeon in Washington, D.C., tells Allure about “case reports of women with long-term shoulder issues after having [under-the-muscle] breast augmentation.” Turns out, deconstructing the chest muscle during surgery can sometimes affect the biomechanics of the shoulder. For so long, he says, “we just kind of accepted, like, Oh, you’re going to have shoulder pain, because you have implants.” But not any more, he says: “I think we can do better.”

The resurgence of subfascial augmentation has been helped along considerably by advancements in breast implants—the latest ones hold their shape and resist rippling, so they work well in front of the muscle (otherwise, you’d see the folds through the skin)—as well as soft tissue scaffolds, a.k.a. “internal bras,” which are absorbable materials designed to support the implants, like little hammocks, during healing. Beyond keeping the implants in place (so surgeons needn’t rely on the muscle for stability), they thicken the surrounding tissues over time to minimize common implant complications. (More on that soon.)

While all of these components contribute to the modern breast augmentation, the process is ultimately ruled by each patient’s aesthetic desires. And, here, again, women are voicing their preferences, in no uncertain terms, and refusing to be swayed or upsold.

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The look for 2024: Did she or didn’t she?

For years, we’ve been hearing about patients downsizing—and it’s true, to an extent, in many parts of the country. But in 2024, breast goals are more nuanced, evoking a certain feeling rather than merely communicating a specific size.

What’s trending is “a did-she-or-didn’t-she look,” says Umbareen Mahmood, MD, a board-certified plastic surgeon in New York City. Size-wise, it’s hardly one-for-all—a fact reflected in the spectrum of inspo shots she sees in her practice: Kendall Jenner and Kate Hudson for a “super-natural look.” Halle Berry and Kaley Cuoco for a bit more oomph. Emily Ratajkowski for fullness that doesn’t scream fake.

Women are choosing implants that fit their frame, lifestyle, and overall aesthetic. Those in Beverly Hills are asking for “subtle, pretty, proportionate breasts,” à la Miley Cyrus, Bella Hadid, or Taylor Swift, according to Dr. Killeen. “They don’t want a bolt-on,” she says. “They just want to fit in their clothing better and [for their implants to] not be noticed.”

Cleavage, however discreet, is a must for their patients.

A quiet, balanced augmentation allows women to fill out their favorite bikini tops “and to feel more confident in their bodies,” Dr. Pittman says. His patients “want to have this kind of hidden secret,” he adds. “They don’t want to be scaring kids at the pool with overdone breasts.”

About five years ago, Ashley Gordon, MD, a board-certified plastic surgeon in Austin, dubbed this vibe the “mystery look.” In her practice, it’s usually a small- to mid-C cup, so “patients can play it up or play it down,” she says. “It’s like an accessory instead of just big breasts.” In Houston, board-certified plastic surgeon Kristy Hamilton, MD, frequently fields similar requests. “Ballerina breasts,” as she calls them, “are elegant, refined, and athletic: They look tasteful and sophisticated in a deep V, not overly sexualized.”

For some, getting the look may mean removing implants. During menopause, the tissues in and around the breasts tend to thicken, explains Steven Teitelbaum, MD, a board-certified plastic surgeon in Santa Monica. “Many women start to feel too big—they’ll use the word ‘matronly,’” he says. “They want to look svelte and sporty in their Lululemon or Alo.” That said, he adds, “no matter how small a woman goes, she still typically wants some kind of décolletage fullness.” Other surgeons report the same: Cleavage, however discreet, is a must for their patients. Even those who had breast reductions or explant surgery (i.e. implant removal) in the past are now coming in for small implants or fat transfer to restore that volume to the top of the breasts.

The resurgence of over-the-muscle breast augmentation

Historically, plastic surgeons have placed breast implants in front of or behind the chest muscle, basing the decision on anatomical considerations, individual preferences, and the prevailing science.

When staying in front, they have two options—place the implant under the glandular tissue (subglandular) or under connective tissue (subfascial). But the zone under the glandular tissue is “inherently kind of contaminated,” notes Dr. Pittman, due to the presence of milk ducts and their native bacteria, which are thought to increase the risk of capsular contracture—an abnormal thickening of the scar tissue that forms around the implant. A dreaded complication, capsular contracture can cause discomfort and warp the shape of the breast, leading to revision surgery. With the latest silicone-gel implants used in the majority of American breast augmentations—what surgeons refer to as 5th-generation implants—the risk of capsular contracture is between approximately 12 and 19 percent at 10 years. The very first 6th-generation silicone implant, from Motiva, which is reportedly nearing FDA approval, boasts a capsular contracture rate of less than 1% at four years. (With over a decade of data backing it, and currently approved in 85 countries, the implant is said to have a novel biocompatible surface shown to mitigate the risk of complications.)

Alternatively, surgeons can go subfascial, securing the implant under the fascia, which offers somewhat of a barrier from the glands and potential bacteria. Breast fascia can be robust or flimsy, however, depending on the person, and “you can’t always peel it off the muscle cleanly,” says Dr. Pittman, so in some cases, surgeons may aim for the subfascial space but wind up with more of a subglandular placement. In any case, when an implant is on top of the muscle (be it under glands or fascia), you can sometimes see it through the skin. This occurs mainly in thinner people without much god-given padding and is most glaring when an implant develops ripples instead of being perfectly flush and smooth.

While some surgeons lump the two over-the-muscle techniques together (and conflate their track records), a new review and meta-analysis in the Aesthetic Surgery Journal highlights a key distinction: “The subfascial plane decreases the risk of capsular contracture, hematoma [bleeding], and rippling compared to the subglandular plane,” says Jamil Ahmad, MD, a board-certified plastic surgeon in Ontario and the article’s senior author.

Conversely, burying a breast implant behind the muscle better conceals it—so it can’t be detected through the skin—and more thoroughly shields it from the milk ducts (though, technically, with certain submuscular techniques, the bottom of the implant still touches glandular tissue). There are disadvantages to this method, as well, however, such as “bottoming out”—implants drifting down and out toward the armpits due to muscle compression—and “animation deformity,” the implants bouncing around when the muscle flexes, like during weightlifting. Dr. Pittman makes the point that as exercise preferences have evolved from the aerobics of the '80s to the more intense and strength-centric CrossFit and Pilates trends of 2024, animation deformity has become a greater concern.

With above-the-muscle augmentation making a comeback, its critics question whether the procedure has truly evolved beyond the issues that plagued it when the subfascial approach first arrived stateside from Brazil in the early aughts. Back then, the technique was associated with high rates of capsular contracture and implant visibility. But as Dr. Ahmad points out, studies suggesting that above-the-muscle implants are more problematic than below-the-muscle implants “are over 20 years old and from a time when breast augmentation technique was very different”—less meticulous, less sterile, and less standardized than it is today.

As exercise preferences have evolved, “animation deformity”—the implant bouncing around when the muscle flexes—has become a greater concern.

Many surgeons insist that placing implants partially behind the muscle using the dual plane method, a procedure with rigorous supporting studies, is the gold standard in breast augmentation. But others tell me that women are increasingly rejecting the technique and its animation issues. The pushback began around 2014, with breast reconstruction patients leading the charge. “We started to see a lot of our cancer patients come back years later with bad animation deformities—every time they moved their pec muscle, the implant would go up and down,” says Steven Sigalove, MD, a board-certified plastic surgeon in Scottsdale, Arizona. “It was very annoying and alarming to a lot of them, so we said, ‘Hey, let's take the muscle out of the equation.’” In doing so, he not only alleviated animation worries, but provided a shorter and less painful recovery.

“There are surgeons who still fear [placing implants above the muscle] for capsular contracture reasons,” Dr. Sigalove says, but recent and emerging research shows no difference in complication rates between subfascial and dual plane methods. Doctors Gordon and Chidester say Dr. Sigalove’s work convinced them to adopt the subfascial technique. “For so long, I didn’t do it because I wasn’t going to risk the capsular contracture,” says Dr. Gordon. Now, she and her patients are sold on the technique. “Their breasts look soft and pretty at one week; they can exercise after two weeks; and most have virtually no pain after a couple of days, because we aren’t lifting the pec off the chest wall.” She finds subfascial works particularly well for women with certain breast asymmetries.

While much of the data on the subfascial approach stems from reconstructive cases (involving mastectomy patients with no natural breast tissue), a 2020 systematic review and meta-analysis of 22 studies featuring 3,743 cosmetic patients who had subfascial augmentation reports an “extremely low” 1.01% rate of early capsular contracture. In the articles included in the meta-analysis, patient follow-ups ranged from approximately one month to seven years. “The data is not complete in all of the studies presented [in the article], and there is variability in the follow-up timelines, but this review demonstrates that patients [who have subfascial breast augmentation] tend to be happy, the risk of complications with this approach tends to be low, and while the long-term risk of capsular contracture is not yet determined, the short-term risk is likely low,” says board-certified Beverly Hills plastic surgeon Daniel J. Gould, MD, who co-authored the paper. “It would be helpful to have long-term follow-up studies comparing rates for all styles of breast augmentation,” he goes on to say, but “our study shows that subfascial augmentation may carry benefits over [other techniques].” In his opinion, “subfascial is here to stay.”

It’s important to note that improvements in surgical technique and silicone-gel implant technology over the past decade have dramatically lowered breast augmentation complications across the board, for all methods. “We’ve gotten so much savvier in terms of how we execute this operation,” says Dr. Pittman. “We’re now at our lowest rates of implant rupture, capsular contracture, and reoperation in history.”

In addition to refinements in surgical protocol, “the tools we have at our disposal are so much better than they were years ago,” adds Dr. Sigalove. With fewer leaks and ruptures, modern implants are less likely to trigger inflammation and capsular contracture, regardless of where they live in relation to the muscle. With 5th-generation silicone gel implants (FDA approved circa 2012), “the risk of capsular contracture is about 1.5% per year and it's additive; the risk of implant rupture is 8% at 10 years; and the rate of reoperation is about 3% per year," notes Dr. Pittman. (For context, the previous model of silicone implants, which came to market around 2006, had complication rates of up to 25% at 10 years.)

Since today’s silicone implants are gummier—filled (or even “overfilled”) with highly cohesive gels—they tend to stay full, round, and wrinkle-free when upright, and can sit invisibly over the muscle, in many cases. (Most implants are slightly less full at the top, because the gel accumulates at the bottom; when laying down, the gel is more evenly distributed.) Generally speaking, “if you can pinch two centimeters in the upper part of the breast, you should have ample soft-tissue coverage to camouflage any potential rippling,” says Dr. Sigalove. If the upper edge of an implant still shows, some surgeons will veil it with fat grafting (assuming the patient has fat to spare); others will suggest, at the outset, going under the muscle to skirt the issue.

“There’s no perfect option—there’s just options and you have to figure out what fits best into your life.”

While many of the problems that caused subfascial augmentation to fall out of favor years ago have seemingly been solved, dual-plane proponents still have concerns. According to Dr. Teitelbaum, placing an implant in front of the muscle puts direct pressure on the breast tissue and can distort it over time, much like a sofa leg does a carpet, while also thinning and stretching the skin. “Those of us who do a huge number of revisions see it every single day,” he says.

Michael Edwards, MD, a board-certified plastic surgeon in Las Vegas, who specializes in revisionary breast surgery, concurs: “A large implant on top of the muscle is the biggest mistake I see,” he says, especially when it’s “trying to account for laxity or sagging in a woman who really needs a lift.” Dr. Edwards’ preference for the dual plane is admittedly flavored by the blunders he fixes. “Even if somebody comes in requesting a smaller implant, I’m going to recommend they place it under the muscle,” he adds, since, in his experience, this technique not only delivers more coverage and a prettier result, but fewer potential headaches in the future.

“You pick your poison with breast augmentation,” summarizes Dr. Killeen. There are potential issues no matter where you place an implant. While she believes most people are candidates for the subfascial approach, she acknowledges that “any time you put an implant over the muscle, there’s always a possibility of that upper edge being visible, especially in thinner people.” That said, she adds, when you go under the muscle in someone slim, muscle movement becomes more obvious. Ultimately, “there’s no perfect option—there’s just options and you have to figure out what fits best into your life.”

More crucial than implant position, notes Dr. Teitelbaum, is the size of the implant relative to one’s tissues. Dr. Killeen agrees: “Disproportionate implants are associated with more troubles, no matter where you put them.” When it comes to technique, she advises finding a surgeon you trust and heeding their advice, “because they’ll get the best results if they’re doing what they’re best at.”

The rise of the “internal bra”

Aiding in the rebirth of above-the-muscle augmentation is the popularization of the “internal bra”—a misnomer, PS, as it does not obviate the need for an actual bra. (Sorry.) It involves wrapping implants, partially or completely, in a grippy, flexible, net-like material—akin to surgical sutures, it dissolves in the body—to keep them from sliding down the chest wall over time. Woven polymer-based versions, like Galaflex and Durasorb, lend immediate support and get broken down by the body within two years, triggering collagen formation in the process, which leaves the surrounding tissue stronger. “This is especially beneficial in the lower breast, particularly for women who’ve breastfed babies or had weight fluctuations resulting in weak collagen or thin breast skin, as it serves as a buttress to prevent bottoming out of the implant,” explains Dr. Mahmood.

Unlike the biologic scaffolds of old—such as acellular dermal matrix (derived from processed cadaver dermis) and Strattice (made from purified pig skin)—synthetic forms cost less, don’t stretch, and are potentially less risky. Dr. Pittman recalls various complications with Strattice—from reactions to the animal protein, to infections, to seromas (pockets of fluid that form post-op). “Everybody needed drains [to remove the fluid],” he says. In the pro column for biologics, they integrate really well with the breast tissue, Dr. Hamilton tells me. Aiming to offer the best of both, new “hybrid” scaffolds, which blend synthetic polymers with biologic materials, like sheep stomach, are now finding their way into operating rooms. It’s still too early to judge their performance, surgeons say.

While scaffolds have long been used in breast revisions, lifts, and reductions, some surgeons now reach for them routinely during first-time breast augmentations with implants in front of the muscle. Dr. Chidester used to reserve Galaflex for complications (like implants migrating down or sideways) or cases of poor skin elasticity, but now he uses it in almost 100% of his breast cases as a sort of “prophylaxis,” he says, contending that the long-term boons are worth the hundreds of dollars it adds to the operation. Beyond holding implants in place and shoring up weak tissues, Galaflex, which has been shown in lab studies to have antimicrobial properties, may offer “a protective benefit against capsular contracture,” says Dr. Sigalove, though “further studies are needed to prove this.”

“None of these scaffolds is FDA approved for use in the breast,” Dr. Gordon points out. Rather, they’re approved for general soft tissue support (in hernia repairs, for instance). While they’ve been used in the breast for about a decade and “there are a number of clinical studies demonstrating their efficacy,” adds Dr. Mahmood, their use in breast surgery is considered off label. Galaflex will reportedly begin breast-specific trials within the year.

(For the record, the dissolvable scaffolds used in breast surgery are distinct from—and should not be confused with—the permanent and problem-prone transvaginal mesh, used to repair pelvic organ prolapse, which the FDA banned in 2019.)

Dr. Chidester says that 90 to 95 percent of the breast augmentations he performs today are “subfascial with a gummy implant and an internal bra, plus or minus fat grafting.” (Gummy implants are those 5th generation silicone-gel implants, and fat grafting is used in select cases to hide implant edges, when needed.) But not every surgeon relies on soft tissue scaffolds, it’s worth noting, and not every patient wants them. Dr. Teitelbaum uses them selectively in lifts and reductions (to help keep the breasts high and full and define the breast fold) and in revisions (to reinforce his alterations), but he views them as “a cherry on top of a surgery that’s already well done.” Dr. Edwards says the same—the operation itself should be designed to curb complications and provide the utmost support for the implants. Likewise, Dr. Killeen doesn’t think scaffolds are necessary for basic boob jobs on first-timers. “I get great, natural results with subfascial and subglandular augmentations, without additional procedures, in many patients,” she says. “This is typically a simple surgery—and my advice is don’t make it complicated.”

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Originally Appeared on Allure

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