Aesth Plast Surg (2022) 46:1075–1081
https://doi.org/10.1007/s00266-021-02692-8
ORIGINAL ARTICLE
Breast Augmentation in Athletic Women: A Retrospective Survey
Assessing Pectoral Muscle Function and Implant Aesthetics
Post-Augmentation.
Danika Jurat1 • Dorian Wenzel2
Received: 22 August 2021 / Accepted: 20 November 2021 / Published online: 24 January 2022
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2022
Abstract
Background Breast augmentation is the most common
cosmetic, surgical procedure (1). Implant insertion planes
include subglandular or submuscular. Submuscular aug-
mentation is often preferred in women with less soft tissue
coverage; requiring pectoralis major dissection (2). How-
ever, loss of functional muscle fibres is undesirable in
athletic women who actively train the pectoral region.
Objectives
1. Assessment of pectoralis function and strength after
breast augmentation in athletic women.
2. Augmentation aesthetical satisfaction at rest and whilst
training.
Methods A retrospective survey was sent to female, fitness
competitors with breast implants via social media over a
six-month period. The survey assessed baseline demo-
graphics, pectoral strength (bench press, push-ups, pectoral
fly), aesthetical satisfaction and issues during training
including pain, rippling, firmness and implant movement.
Results Eighty-one participants were surveyed. The mean
age of augmentation was 29.7 (±8.41), and mean age of
survey completion was 37.6 (±7.22) years. Submuscular
augmentation was performed in 72.8% of participants.
Recovery post-operative and time spent training was syn-
onymous. The majority of participants’ pectoral strength
was unaffected or positively affected by breast
& Danika Jurat
danika.jurat@health.wa.gov.au
1
Plastic and Reconstructive Surgery Unit, Royal Perth
Hospital, Perth, Australia
2
Anaesthetic and Pain Medicine Department, Royal Perth
Hospital, Perth, Australia
BREAST SURGERY
augmentation. Assessment of post-operative performance
and training issues of pain, rippling and firmness yielded no
statistically significant difference between groups. Implant
movement during pectoral exercises was 2.5 times more
likely with submuscular augmentations, p= 0.038. Overall,
the majority of the population were very satisfied or sat-
isfied with their breast aesthetic at rest (92.6%) and during
training (79.0%).
Conclusions Breast augmentation in athletic women has a
high satisfaction rate with the majority maintaining or
improving the strength of the pectoral region regardless of
augmentation plane.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors https://www.springer.com/journal/
00266.
Keywords Breast augmentation
Breast implants

Pectoral muscle function
Bodybuilding
Athletic women
Introduction
Breast augmentation is the most popular cosmetic, surgical
procedure [1, 2]. Planes of implant insertion include sub-
glandular and submuscular [2, 3]. In women with low
volume of native breast adipose tissue, such as athletic
women, submuscular placement is often preferred for
improved implant coverage and reduced risk of medial
rippling [2, 3].
Submuscular placement of an implant requires dissec-
tion of the pectoralis major, therefore potentially dimin-
ishing strength due to reduction of functional muscle fibres.
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Pectoralis major strength and function are important to
athletic women, in particular powerlifters, bodybuilders
and CrossFit competitors who are required to regularly
train the chest area to be competitive in their chosen sport.
The prime example is powerlifting where one of the three
key movements is the bench press.
Limited research has been completed in this area
assessing post-operative pectoralis major strength and
function combined with aesthetical satisfaction of the
athletic woman who undergoes breast augmentation and
continues to train the pectoral region. Particularly lacking
in the literature is longer-term follow-up.
Objective
3. Assessment of function and strength of the pectoralis
major post-subglandular or submuscular breast aug-
mentation in athletic women.
4. Aesthetical satisfaction post-augmentation at rest and
whilst training.
Method
A survey was sent to female, fitness competitors having
undergone a breast augmentation via social media,
including Instagram and Facebook, over a six-month per-
iod. This included approaching women through specialized
bodybuilding, powerlifting and CrossFit competitor
groups.
The survey assessed basic demographic information
including current age, age at time of augmentation and
implant pocket plane. Following this, the survey assessed
level of training and whether the participant was a com-
petitor in fitness competitions including powerlifting,
bodybuilding and CrossFit. We established whether the
participant competed pre- and/or post-augmentation and
whether the augmentation had affected the strength of their
bench press, push-up or pectoral fly. In addition to their
subjective strength assessment, participants commented if
these exercises caused pain post-augmentation, if they
could feel the implant moving during exercise or if they
experienced firmness or rippling whilst training. Finally,
the participant commented on their overall satisfaction of
their breast aesthetic whilst at rest and during training.
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Aesth Plast Surg (2022) 46:1075–1081
Results
Data analysis
Descriptive statistics
Descriptive statistics of normally distributed continuous
variables will be expressed as mean and standard deviation
(SD) and categorical variables as number and proportion
(%). Comparative statistics included t-tests, Chi-squared
tests and Fisher’s exact test where appropriate.
The mean age of the 81 participants surveyed was 37.6
(±7.22) years with 84% aged between 26 and 45 years.
The mean age at time of augmentation was 29.7 (±8.41)
years with 79% aged between 18 and 35 (Table 1).
Implants were inserted in the subglandular plane in 27.2%
of the population. The remaining 72.8% augmented below
the pectoral muscle (Table 2).
Prior to augmentation, 35.8% of women had participated
in a fitness competition, with the figure rising to 66.7%
post-augmentation (Table 3). Recovery post-operative was
assessed by return to full training with subglandular par-
ticipants requiring a mean of 7.05 (±1.20) weeks and
submuscular participants 6.95 (±1.38) weeks. Implant
location did not significantly affect return to full training
(t(75)=0.287, p= 0.775) (Table 4).
In regard to regular training, subglandular participants
trained a mean of 6.55 (±1.37) hours compared to 6.62
(±1.60) hours by the submuscular cohort per week
(t(78)=0.181, p= 0.857) (Table 5). Of that time spent,
subglandular participants spent a mean of 1.26 (±0.66)
hours exercising their pectoral region with the submuscular
group utilising 1.21 (±0.57) hours (t(77)=0.329, p= 0.743).
The difference in time spent performing general or pectoral
specific training between augmentation plane groups was
not significant (Table 6).
Of the subglandular augmentation population, 86.4%
had the same or improved bench press performance on
return to full training compared to 70.4% of the submus-
cular population. X2( 2, 76)= 3.12, p=0.21 (Table 7). 95.5%
of the subglandular and 87.9% of the submuscular popu-
lation experienced no pain during bench press post-breast
augmentation on return to full training, Fisher’s exact test
yielding p= 0.432 (Table 8).
Push-up performance post-augmentation remained lar-
gely unchanged in the subglandular population with 68.2%
reporting the same and 27.3% reporting an improved push-
up. 56.1% of the submuscular demographic stated their
push-up was the same and 44.4% delineated an improve-
ment. X2(2, 79)= 3.64, p= 0.16 (Table 9). Again, the
majority had no pain with performance, 95.5%
Aesth Plast Surg (2022) 46:1075–1081 1077

Table 1 Age of augmentation

Age (years) Current (n = 81) Age at time of augmentation (n=81)
and survey completion
18-25 2 (2.5%) 32 (39.5%)
26-35 31 (38.3%) 32 (39.5%)
36-45 37 (45.7%) 12 (14.8%)
46-55 11 (13.6%) 5 (6.2%)

Table 2 Implant insertion Table 4 Time between augmentation and return to full training
Implant location (n = 81)
plane
Time (weeks) Implant location (n=77)
Above 22 (27.2%)
Below the muscle 59 (72.8%) Above Below Total

2 0 (0.0%) 0 (0.0%) 0 (0.0%)

subglandular and 84.7% of the submuscular population, p= 3 0 (0.0%) 0 (0.0%) 0 (0.0%)
0.272 (Table 10). 4 1 (5.0%) 7 (12.3%) 7 (10.4%)
The third assessed exercise was the pectoral fly. 75% of 5 1 (5.0%) 0 (0.0%) 1 (1.3%)
the subglandular population experienced the same perfor- 6 5 (25.0%) 14 (24.6%) 19 (24.7 %)
mance during the fly, with 20% reporting an improvement. 7 2 (10%) 4 (7.0%) 6 (7.8%)
52.7% of the submuscular participants stated their fly 8? 11 (55%) 32 (56.1%) 43 (55.8%)
performance was the same, with 23.6% experiencing an Total 20 57 77
improvement. X2(2, 75)= 4.05, p= 0.13 (Table 11). Pain
continued to be low amongst both groups with 90.5% of the
subglandular group denying pain during the fly and 83.1%
Table 5 Time spent training per week
of submuscular participants, p= 0.502. The fly replicated
the bench press and the push-up with no statistically sig- Time (hours) Implant location (n = 80)
nificant difference between performance or pain and the Above Below Total
implant plane (Table 12).
Of the demographic that experienced pain, 50% expe- 0-2 0 (0.0%) 2 (3.4%) 2 (2.5%)
rienced pain across all three exercises, with the remainder’s 2-4 1 (4.5%) 2 (3.4%) 3 (3.7%)
specific to one or two out of the three assessed movements. 4-6 6 (27.3%) 9 (15.5%) 15 (18.8%)
A total of 11.1% suffered with bench press, 12.3% during 6-8 9 (40.9%) 29 (50.0%) 38 (47.5%)
push-ups and 15% whilst performing a pectoral fly. 8? 6 (27.3% 16 (27.6%) 22 (27.5%)
Further complications assessed included rippling, firm- Total 22 58 80
ness and movement of the implant during training. A
combined total of 22.2% of the cohort experienced implant
rippling during training. This included 22.7% of the sub- group and 35.6% of the submuscular group, p= 0.179
glandular group compared to 22.0% of the submuscular, p= (Table 14). Implant movement was experienced by 18.2%
1.000 (Table 13). of subglandular participants during training compared to
Firmness was experienced by 30.9% of the assessed 45.8% of the submuscular group, p= 0.038. This was a
demographic. This included 18.2% of the subglandular statistically significant difference (Table 15).

Table 3 Fitness competitor pre- or post-augmentation

Pre-augmentation (segregated by subsequent implant location) (n=81) Post-augmentation implant location (n=81)
Fitness competitor Above Below Total Above Below Total

Yes 7 (31.8%) 22 (37.3%) 29 (35.8%) 14 (63.6%) 40 (67.8%) 54 (66.7%)

No 15 (68.2%) 37 (62.7%) 52 (64.2%) 8 (36.4%) 19 (32.2%) 27(33.3%)
Total 22 59 81 22 59 81

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1078 Aesth Plast Surg (2022) 46:1075–1081

Table 6 Time spent training pectoral region per week Table 11 Pectoral fly performance post-augmentation
Time (hours) Implant location (n=79) Performance Implant location (n=75)
Above Below Total Above Below Total

0 3 (14.3%) 4 (6.9%) 7 (8.9%) Reduced 1 (5.0%) 13 (23.6%) 14 (18.7%)

0.5–1 4 (19.0%) 22 (37.3%) 26 (32.9%) Same 15 (75.0%) 29 (52.7%) 44 (58.7%)
1-2 9 (42.9%) 21 (36.2%) 30 (38.0%) Improved 4 (20.0%) 13 (23.6%) 17 (22.7%)
2? 5 (23.8%) 11 (19.0%) 16 (20.3%) Total 20 55 75
Total 21 58 79

Table 12 Pain during pectoral fly post-augmentation

Table 7 Bench press performance post-augmentation
Pain with exercise Implant location (n=80)
Performance Implant location (n=76)
Above Below Total
Above Below Total
Yes 2 (9.5%) 10 (16.9%) 12 (15.0%)
Reduced 3 (13.6%) 16 (29.6%) 19(25.0%) No 19 (90.5%) 49 (83.1%) 68 (85.0%)
Same 13 (59.1%) 21 (38.9%) 34 (44.7%) Total 21 59 80
Improved 6 (27.3%) 17 (31.5%) 30 (38.0%)
Total 22 54 76

Table 13 Noticeable implant rippling during training:

Table 8 Pain during bench press post-augmentation Issues whilst training Implant location (n=81)

Pain with exercise Implant location (n=81) Above Below Total

Above Below Total Yes 5 (22.7%) 13 (22.0%) 18 (22.2%)

No 17 (77.3%) 46 (78.0%) 63 (77.8%)
Yes 1 (4.5%) 8 (13.6%) 9 (11.1%)
Total 22 59 81
No 21 (95.5%) 51 (86.4%) 72 (88.9%)
Total 22 59 81
At 92.6%, the majority of participants were satisfied or
very satisfied with their breast aesthetics at rest, with this
number dropping to 79.0% during training. 3.7% of the
Table 9 Push-up performance post-augmentation total population were unsatisfied or very unsatisfied at rest,
Performance Implant location (n=79) and 9.9% were unsatisfied or very unsatisfied during
training. Proportions were similar across the two cohorts
Above Below Total
with no statistically significant difference at rest: X2(4,
Reduced 1 (4.5%) 13 (22.8%) 14 (17.7%) 81)= 7.39, p= 0.12, or during training: X2(4, 81)= 1.82, p=
Same 15 (68.2%) 32 (56.1%) 47(59.5%) 0.77 (Tables 16, 17).
Improved 6 (27.3%) 12 (21.1%) 18 (22.7%)
Total 22 57 79
Discussion

This study was a retrospective survey with an eight-year

difference between the mean age of augmentation and
Table 10 Pain during push-ups post-augmentation
mean age of survey completion. This meant the majority of
Pain with exercise Implant location (n=81) the cohort had fully recovered from their breast augmen-
Above Below Total tation and resumed training at an intensity level equivalent
to pre-operative. The extended period meant the partici-
Yes 1 (4.5%) 9 (15.3%) 10 (12.3%)
pants were likely to have experienced the assessed com-
No 21 (95.5%) 50 (84.7%) 71 (87.7%) plications, if they were to develop.
Total 22 59 81 Three quarters of the participants had a submuscular
implant placement, thus having a portion of the pectoralis

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Aesth Plast Surg (2022) 46:1075–1081 1079

Table 14 Movement of the

Issues whilst training Implant location (n=81)
implant during training:
Above Below Total
Yes 4 (18.2%) 27 (45.8%) 31 (38.3%)
No 18 (81.8%) 32 (54.2%) 50 (61.7%)
Total 22 59 81

Table 15 Firmness of the implant during training operative regime. Time frame recommendations on return
Issues whilst training Implant location (n=81)
to training varied between surgeons. Similar time was spent
training the pectoral region between the assessed groups.
Above Below Total Participants of both cohorts reported high percentages of
Yes 4 (18.2%) 21 (35.6%) 25 (30.9%) the same or improved bench press, push-ups and pectoral
No 18 (81.8%) 38 (64.4%) 56 (69.1%) fly exercises. Hypothesises for why this may occur include
Total 22 59 81 the reduced range of motion required to perform bench
press or push-ups, with both exercises restricted by bar to
chest or chest to ground distance. In the submuscular
major dissected during the operation. Given the athletic demographic, theoretically, the additional tension placed
nature of the demographic, with 94% training for more on the pectoralis muscle fibres post-insertion by the
than 4 hours a week, it is highly likely that the participants underlying implant could result in increased muscular
had lower body fat percentages, leading to surgeon pref- hypertrophy. In addition, the increased muscular fibre
erence being submuscular placement for improved implant stretch the implants place on the pectoralis major fibres,
coverage and a more natural cosmesis [3, 4]. Gravidity and potentially allows greater power generation as more actin
parity of the demographic were not assessed. This study did and myosin filaments overlap prior to forceful contraction.
not separate submuscular augmentations based on level of Cosmetic breast augmentation is undertaken for a vari-
pre-pectoral dissection or quantify implant size or texture ety of reasons, with a post-operative increase in self-con-
due to participants’ inconsistent recall of exact nature of fidence often cited as a primary factor [5, 6]. This increased
implant and placement. level of confidence may be one of the reasons behind the
Recovery to full training post-operative was synony- proportion of the cohort entering bodybuilding, powerlift-
mous between the two assessed groups, with our cohort ing and CrossFit competitions doubled post-augmentation.
waiting close to two months before resuming their pre- Self-confidence has been repeatedly demonstrated to be an

Table 16 Satisfaction with

Satisfaction with breast aesthetics At rest (n=81)
breast aesthetics at rest
Above Below Total

Very satisfied 9 (40.9%) 43 (72.9%) 52 (64.2%)

Satisfied 10 (45.5%) 12 (20.3%) 23(28.4%)
Neither 1 (4.5%) 2 (3.4%) 3(3.7%)
Dissatisfied 1 (4.5%) 1 (1.7%) 2 (2.5%)
Very dissatisfied 1 (4.5%) 1 (1.7%) 1 (1.2%)
Total 22 59 81

Table 17 Satisfaction with

Satisfaction with breast aesthetics During training (n=81)
breast aesthetics during training
Above Below Total

Very satisfied 7 (31.8%) 26 (44.1%) 33 (40.7%)

Satisfied 10 (45.5%) 21 (35.6) 31 (38.3%)
Neither 3 (13.6%) 5 (8.5%) 9 (11.1%)
Dissatisfied 1 (4.5%) 5 (8.5%) 6 (7.4%)
Very dissatisfied 1 (4.5%) 2 (3.3%) 2 (2.5%)
Total 22 59 81

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indicator for improved athletic performance, therefore
potentially contributing to the improved performance of a
large proportion of our assessed cohort [7, 8].
Low proportions experienced complications secondary
to their breast augmentation during training. Close to 90%
of both demographics experienced no pain across all three
assessed exercises. The exercise that triggered pain in the
greatest number of participants was the pectoral fly at 15%.
Whilst the activation of the pectoralis is similar across the
bench press and push-up, the fly is a different mechanism
of action. Increased levels of pain may be due to the dif-
ferent nature of the exercise with greater activation of
pectoralis fibres in both the eccentric and concentric por-
tions of the exercise.
The majority of the population were satisfied or very
satisfied post-procedure. This high rate of satisfaction can
be attributed to several factors. One likely contributor is the
ability to maintain a more traditional female or feminine
breast aesthetic at a lower body mass index for the female
athlete. The reduction in satisfaction of breast aesthetic
during training is thought to be due to the assessed issues of
implant rippling, movement or sensation of firmness.
Almost half of the population with submuscular implants
experienced movement of the implant during training, with
muscle action deformity occurring due to muscle adher-
ence to the fibrous capsule of the implant. Subglandular
placement resulted in reduced sensation of implant move-
ment during pectoral muscle exercise.
The subglandular population had slightly lower rates of
self-reported rippling, though this difference did not reach
statistical significance. Implant insertion in the submuscu-
lar plane would reduce visible rippling in the medial
quadrants of the breast in leaner patients, but rippling may
still be demonstrated in the lateral and inferior zones. In a
female with limited native breast tissue, subglandular
placement may increase the risk of a discernible implant
edge superiorly and has higher rates of capsular contracture
compared to its submuscular counterpart [2, 7].
One weakness of our research is the subjective nature of
the reporting, relying on patient self-assessment of strength
and function. However, over half of the population
demographic included in our survey were powerlifters,
who closely monitor and record strength quantitatively,
measuring the most weight lifted with training programs
designed around percentages and incremental increases of
their one repetition maximum.
Previously, only one small survey of 20 participants in
2004 by Sarbak et al. has been completed to assess athletic
women’s strength, pain or discomfort during use of the
pectoral muscles and aesthetic satisfaction post-augmen-
tation [9]. This survey was completed via the authors
touring local Florida gyms for participants that met the
criteria of augmented breasts and regular trainers of the
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Aesth Plast Surg (2022) 46:1075–1081
pectoral region. With the ease of social media allowing
ready identification of suitable participants, this appeared
the opportune time to conduct more extensive research in
the area. This is particularly important given the popularity
of breast augmentation in areas such as bodybuilding, a
population who values both overall aesthetics and muscle
function. Further literature in this area empowers women
and surgeons to make educated decisions about whether to
implant, and if so, the optimum location.
Supplementary research has been conducted by Roxo
et al. which assessed functional and volumetric analysis of
the pectoralis major by MRI and isokinetic dynamometer
after submuscular (all of the dual plane variety) breast
augmentation in 30 women [10]. This study was completed
in the general population, with women who had a history of
‘‘intense muscle activity’’ excluded. Follow-up was at 3, 6
and 12 months. The control group were patients who did
not undergo an operation. The results demonstrated a
radiological decrease in muscle volume and a decrease in
adduction strength, but no correlation of statistical signif-
icance between the 2. There was no change to strength of
abduction. Anecdotally, all participants reported no per-
ceived change to strength. The additional movements of
the pectoralis major including flexion and medial rotation
of the humerus or thoracic elevation were not assessed. If
further, similar research was performed with athletic
women, a control group of patients undergoing subglan-
dular implant insertion would allow consideration of
muscle wastage due to a post-operative recovery period
with time away from training without loss of muscle fibres
secondary to incision.
An additional study by Beals et al. assessed strength
performance of the pectoralis major muscle after subpec-
toral breast augmentation in 2003 [11]. Again, this study
assessed the average female undertaking augmentation and
not the athletic woman. Their study followed 20 female
patients, all of which had strength assessment of internal
rotation and extension/adduction at 2 and 6 weeks. This
was prior to complete recovery and likely to induce pain
for the subjects. Only 9 patients completed the long-term
follow-up at an average of 10 months. Strength perfor-
mance of the majority of the patients was fully recovered
by 6 weeks and was retained or improved at long-term
follow-up.
Ideally future research in the area would be a prospec-
tive study to objectively measure pectoralis major strength
pre- and post-operatively. This would include standardized
training and long-term follow-up in a large population
accounting for the recovery period and associated muscle
wastage with disuse. Currently, the results from our
research are encouraging for the athletic woman consid-
ering breast augmentation who is unwilling to sacrifice
pectoralis major function and strength.
Aesth Plast Surg (2022) 46:1075–1081
Conclusion
Overwhelmingly, both subglandular and submuscular
breast implants did not significantly affect strength or cause
discomfort during pectoral muscle training. Return to full
training was equivalent between the two cohorts with the
majority of patients very satisfied with their breast aesthetic
at rest and whilst exercising. Sensation of implant move-
ment during pectoral training was the only significant dif-
ference; experienced by a larger proportion of the
submuscular population.
Funding There was no funding.
Declarations
Conflicts of interest The authors declare that they have no conflicts
of interest to disclose.
Ethical approval Ethical approval was not required to conduct this
retrospective study.
Informed consent Informed consent has been provided by all
participants.
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