Under the muscle is usually prefered

In my practice I place most implants under the muscle. The best position for an implant whether under the muscle, (sub-muscular), or over the muscle, (sub glandular), depend upon the anatomy of the woman. 

Several factors need to be considered when determining implant position:

1. The amount of tissue covering the implant.  In most women who are thin with little breast tissue, it is usually better to go under the muscle.  The extra layer of tissue over the implant usually provides a better feel and appearance.
2. The type of implant needs to be considered as well.  Saline implants tend to have a stiffer shell and are more prone to ripples.  I place all saline implants under the muscle.  While the silicone gel implants have a more natural feel, I still place the vast majority of these under the muscle because they seem to have a more natural shape in this position. 
3. The size of the implant.  An implant that is too large for a woman's frame tends to create an unnatural fullness in the upper part of the breast

For most patients placing the implants under the muscle will give a more natural appearance and is a more durable result.  There is less stretching of the skin and breast tissue and less drooping over time.  There is also some evidence that the chance of developing capsular contracture may be reduced in this position.  A well positioned implant, under the muscle through a inframammary incision gives an excellent result and is very reproducible

There are very specific situations where placing the implant over the muscle may be better for the patient:

    1.  To help correct moderate drooping in a patient who does not want a breast lift .  The patients must have thicker skin or at least a large B or small C cup breasts to help camouflage the implant and a somewhat larger implant is required.  The patient must understand that the breast implants may change over time ultimately leading to the need for a breast lift.

      2.  Breast Asymmetry  where one breast has very little skin beneath the nipple (sometimes called a tuberous breast disorder)  This position helps stretch the skin along the lower part of the breast and improve symmetry.

       3.  Body builders who do not want their Pectoralis Major muscle disturbed.  The implants in these women are understandably more visible because of their often low body fat percentage.

There are some others but for almost all women, under the muscle gives a more natural appearance and causes less trouble.

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