UTM vs OTM – Where to Place Your Implants

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When you are choosing your reconstruction after a mastectomy, there are so many decisions to make. Do you want implants? What size/type/shape implants? And what is the best placement – UTM vs OTM?

Defining UTM vs OTM

But first, what exactly do I mean by UTM and OTM? These acronyms mean “Under the Muscle” (or Sub-Pectoral) and “Over the Muscle” (or Pre-Pectoral) and refer to where the implant is placed on the chest in relation to the Pectoralis Major muscle. Like everything, each of these has clear pros and cons and some that are not so clear.

When placed UTM, the Pectoralis Major muscle is cut and a pocket is created underneath it to hold the implant in place.

For OTM, the muscle is left in tact and a pocket is created between the muscle and the skin, where the original breast tissue was located.

Comparing UTM vs OTM

UTM vs OTM implants

This is where trying to decide which way to go starts to get a little murky. While I will give you a brief rundown of the main pros and cons, remember that everyone is different, so even if you feel one method may be best for you, talk to your medical team about both and your lifestyle to determine exactly which suits you best.

UTM is the more “traditional” of the methods used. You are likely to find more “old school” surgeons use this method. When I discussed this with my surgeon he said UTM had proven itself long term, whereas OTM was only becoming popular more recently to combat the issues associated with UTM and therefore long term results were not yet so well known.

This doesn’t mean the long term results of OTM are any better or worse than UTM, just that there’s not a lot of data yet.

UTM implants are often considered to be more uncomfortable, even more painful, than OTM. This is not a given, but does seem to make sense given that the pec muscle is cut and stretched during the procedure.

The other major downside that many people report with UTM implants is what is called “animation”. The best way to imagine this is to think of a well muscled male chest and how the pec muscles move when flexed.

Some people are really bothered by the animation, others barely notice it. This can be particularly troublesome to people who use the chest muscles a lot, for example, those who like to work out in the gym or have a physical job.

Sometimes the constant animation has been known to gradually separate the implants, pushing them further and further into the armpits.

OTM may help with animation, but their aesthetic downside is rippling. Because the implant is sitting right underneath the skin, there is not much padding to hide the look of the implant. As the implant moves, particularly when leaning forward, the ripples and folds can be clearly seen. It is also easier to see the edges of the implants too, with a less natural shape.

Often rippling can be correctly with fat grafting, but this is usually another procedure and it can be quite painful with only so-so results.

This is where fat is taken from another part of the body, usually the stomach or thighs (think liposuction) and transferred into the areas of the breast that needs plumping up. It is not unusual to have more than one round of fat grafting, with up to 50% of the fat melting away once it has been moved.

UTM is often recommended to people with a smaller frame as it provides more support for the implant. OTM requires some additional support, usually Allerderm (cadaver skin) is used to create a sling to hold the implant in place.

Since the muscle is being cut during UTM, the healing time can sometimes be longer than for OTM.

OTM tends to give a more natural droop to the breast, because the implant is being placed exactly where the original breast tissue was removed from. UTM tends to give a perkier, higher look.

With all these conflicting pros and cons, it’s clear neither option is the best solution in all cases. So how do you choose?

Why I Chose UTM

It can be really hard to decide which is the best option to go with here. I have to admit I was mostly lead by my surgeon. I saw a whole pile of photos of reconstructions he had done.

He explained that he only showed middle-of-the-road results, so it was possible my result would be better or worse than what I was looking at. It was reassuring he wasn’t showing me only the best results, but it still made it hard to decide, because all the photos he showed me were UTM.

And here’s where a lot of the decision was influenced. You see, like most surgeons, mine has a preference for the type of surgery he does, and for him it’s UTM reconstruction. He also explained that this would be best for me due to my smaller frame.

I had read about all the pros and cons of the two methods, and I chose to go with what my surgeon recommended – after all, he is the expert who has seen this on many other women, whereas I had no idea at all.

So how did it turn out?

If you have looked at other pages of my blog – like this one – then you will know that I am quite happy with my UTM implants. I do not have any pain or weakness. Yes, there is animation, but I don’t notice it at all in my day to day life, only when I do it on purpose. It probably happens, but it clearly doesn’t bother me.

The video below will give you an idea of what my animation looks like. Bear in mind I am trying to make this as bad as I can by squeezing the muscles hard. This does not happen during my normal day.

The muscles protect my implants and provide enough of a buffer between the skin and implants so that I did not need to worry about any fat grafting. Sure, a. little more fat around the top could help make them more natural, but I have happy enough with the look to not put myself through the pain and another surgery.

While it’s not really a pro because there is no proof it’s an issue with OTM, I like the thought that all my remaining breast tissue (and there is always a tiny amount left) sits on top of the muscle, right underneath my skin. So if the cancer was to grow back, it should be easier for me to find. Any little thing that helps to bring peace of mind is a bonus in my eyes.

So while UTM is often seen as the less popular option now, it has worked out really well for me. If you are about to make this choice, know that it is possible to have a UTM outcome with no pain, no negative effects from the animation and a nice aesthetic look.

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  1. Thank you for sharing your journey! Comforting to read how others make it through this unique experience. I’m between the bilateral mastectomy and reconstruction. Every day is a new day:)

    1. Thank you – and good luck with your reconstruction. I can promise you it might be tough now, but there is a light at the end of the tunnel 🙂

  2. Hi Josie,
    I am doing some research on the UTM vs OTM. In 2021 I had DIEP but unfortunately there wasn’t enough projection so I had small implants placed UTM. Two years later I am still having some muscle cramping in and around the breast on the cancer side. My
    PS said I can switch to OTM but I’m not sure I want to do that. Did you or do you have any muscle cramping?

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