In my case, which implant placement should be preferred; under or over the muscle? (photo)

I have two doctors with very different opinions on everything. I am very concerned about making the right decision. I want my breasts to bounce naturally, and I do not want animation deformity doing day to day things which involve my chest muscles, or going to the gym. However, I'm don't want to be able to feel my implants, want a natural slope without roundness, and am concerned about further premature sagging. What do I do?!

Doctor Answers 6

Deciding on Implant placement with conflicting goals

Thank you for your question!

I can see that you prefer natural feeling and natural-looking breasts. Below I mention important characteristics for getting natural results.

Natural breasts have the following characteristics:

  • The areola – dark pigmented region around the nipples – should not be large relative to your nipple
  • The nipple should be above the breast fold – inframammary fold
  • The 2 nipples should form an equilateral triangle with the notch of your breast bone
  • The breasts should not be sagging
  • The nipples should sit directly behind the part of the breast that projects the fullest
  • The breasts should appear symmetrical
  • A recent study by Dr. Mallucci and Dr. Branford, titled “Shapes, Proportions, and Variations in breast Aesthetic Ideals,” gives us 4 set of ideals in beautiful and natural-looking breasts. They are as follows:
  • An upward pointing nipple (angled at 20 degrees)
  • A slope in the upper pole of the breast
  • A tight curvature (convexity) in the lower pole of the breast (i.e., below the nipple)
  • An upper pole to lower pole ratio of 45:55 (i.e., the percent of fill below the nipple should be 55% compared to 45% above the nipple)

If your breasts meet these ideals and those I mentioned above, they will look natural. 

That being said, there are many factors that go into creating natural-looking breasts, and a combination of the right choices contributes to achieving the desired result. I only mention the implant size, shape, and pocket of placement. However, other factors like the profile of the implant, and incision placement also make a difference.

The size of the implant – a large implant that exceeds your breast boundaries, or overly stretches your breasts, or is too round will make your breasts look unnatural. In fact, there is higher likelihood of bottoming out (i.e., breasts sitting too low on the chest, nipple sitting too high on the breast, etc.), double bubble deformity, implant malposition, implant visibility, breast sagging, and breast tissue wasting. So going big is good, but going beyond limits will get you in big trouble…pun intended.

A board-certified surgeon will always determine a suitable range for the implant volume after conducting some breast measurements and this is called tissue-based planning. Measurements such as breast base width, the amount of breast skin stretch, nipple to breast fold distance under maximal stretch, along with skin quality and chest wall asymmetry assessments have to be looked into. The combination of these measurements will help determine tissue coverage and the required implant volume to optimally fill the breasts. For example, if your breast base is very wide, we will require a higher implant volume to avoid the “rock in a sock” appearance.

The shape of the implant – majority of surgeons prefer round and smooth implants, but if your breasts do not have a natural shape to begin with as we see in patients who have tuberous breasts, then you may require the use of anatomic implants (tear-drop shaped implants) whose lower half is more loaded in volume than the upper half corresponding with the desired natural look.

Pocket – The decision to go behind the muscle or over the muscle has to do with the amount of soft tissue coverage – “padding” under the skin. Choosing a pocket that is tight with sufficient soft tissue coverage not only prevents implant visibility, palpability, and risks of excessive stretching on the breast, but also excessive implant movement into the outer or inner sides of the breasts. A hand-in-glove fit for the implant allows for a natural and long-lasting result. Your surgeon will do a pinch test in the upper pole of the breast to see how much “padding” you have. If you have less than 2 cm, then you do not have much padding and it would be best to go under the muscle. Generally speaking, if your ribs are visible under the muscle, then you do not have much “padding.” If however, you have more than 2 cm of tissue, then you have the option to go over the muscle or under the muscle.

Which pocket do you prefer?


If you are hoping to fully preserve the functionality of the pectoralis major muscle due to athletics or body building, or if you have a shapeless, constricted, tuberous, sagging breasts without cleavage, then over the muscle may be a better option.
  • Over the muscle implant placement causes less trauma to the chest muscles, and the implants will not be subjected to any pressure or injury due to muscle movement.
  • The implant can directly apply pressure on breast tissue to shape the breasts.
  • However, over the muscle implant placement may have higher risks of breast tissue wasting, interference with mammography, and capsular contracture compared to under the muscle placement.
  • Higher risk of implant visibility and palpability is possible if you are thin, and this can be fixed used fat grafting where areas with less tissue coverage are filled with your own fat to provide better contour and coverage.


Under the muscle (partially submuscular) is a preferred option for many surgeons because the muscle helps to maintain a slope for the upper pole while allowing for a curvature in the lower pole, while over the muscle will mostly make your breasts appear round and augmented.
  • In thin patients, additional coverage by the muscle reduces the risk of implant visibility in the upper and inner sides of the breasts. It also reduces risk of synmastia, and provides less interference with mammography and breast imaging. It also brings lower rates of capsular contracture.
  • However, under the muscle implant placement may allow the chest muscles to put pressure on the implant distorting the breast shape and position in the long-term. You may experience more pain following surgery due to the dissection of some muscle attachments and you may lose strength while flexing your chest muscle and is not suitable for athletes and body builders.

So which pocket allows a more natural look?

There is a difference in opinion, but if we are trying to meet those ideals I described in the beginning, then under the muscle (partially submuscular) is the best option because the muscle helps to maintain a slope for the upper pole while allowing for a curvature in the lower pole, while over the muscle will just make your breasts appear round and augmented.

Since you have conflicting goals for your breasts, it will be difficult to fulfill all desires. You have to decide what goals are more important for you and make certain sacrifices while making decisions.

If you give more importance to maintaining strength and integrity of your chest muscles, and want to avoid animation deformity, then over the muscle is a better option.

If you do not want to feel the implants, want a natural slope without roundness, without the accelerated process of breast tissue wasting and sagging, then under the muscle is a better option. From my surgical experience, majority of the athletes, bikini-models, body-builders go for the under the muscle implant placement because they want the natural slope even though there is risk of animation deformity and slight decrease in muscle strength.

An alternative option to this would be to have over the muscle implant placement with anatomical implants coupled with fat grafting to provide appropriate breast tissue coverage.

It is important that you communicate your goals very clearly, but understand that you need to have realistic expectations.

Please seek an in-person consultation with a board-certified plastic surgeon and share your full concerns, desires, and expectations.

Hope this helps, and best of luck!

Toronto Plastic Surgeon
4.9 out of 5 stars 416 reviews

There is no no argument for subglandular

There are many advantages to sub muscular dual plane placement and very many disadvantages to sub glandular placement. I would see no indication to do anything but sub muscular.  This can be best accomplished with the armpit approach. The most sophisticated approach to breast augmentation is through the armpit with a surgical camera (transaxillary endoscopic). Using this modern approach the space can be crafted under direct vision, with virtually no bleeding and no postoperative bruising. Most importantly, the shape of the breast is meticulously created. The other, older methods of insertion are technologically less advanced. Both silicone and saline implants can be placed through the armpit by a surgeon with skill and experience using this approach. The incision in the crease is the oldest method of placing the implants and puts a scar directly on the breast. Subglandular silicone implant placement is the historical approach to this surgery, and was widely used in the 1960's. The implant edges are more visible, the risk of rippling is higher, the implant is in contact with the non-sterile breast tissue so the risk of infection and capsular contracture is higher. The interface between the breast tissue and the muscle is blurred so the implant interferes with mammography more than sub muscular placement. The blood supply surrounding the implant is worse so the risk of capsular contracture is higher. The support for the implant is less so there is more long term shape abnormalities and sagging. The look of a sub glandular implant is much less appealing than a sub muscular implant. The placement of sub glandular implants makes any subsequent revision surgeries more complicated and less successful. There are no advantages to sub glandular implant placement.

Implant Placement - Under or over the muscle?

Thank you for your question.  From the photograph you appear to already have some moderate amount of breast tissue, but as you have a slight sagginess (ptosis), a round implant would accentuate the shape of the upper pole (half) of your breast, which you do not want. You naturally do not want your breasts to move unnaturally or to be visible or palpable. With all these criteria, probably a reasonable option is to place in teardrop-shaped silicone implants, using a technique called dual-plane. Only the upper half of the implant would be covered with muscle and in my experience this is less likely to cause animation deformity. There are several causes of premature sagging of breasts, such as pregnancy, skin type, as well as heavy implants. I think a careful compromise as to the size of the breast implants is important, as well as considering other augmentation techniques, such as lipofilling (the injection of fat harvested from another part of your body, such as the abdomen or love handles). This is a very good technique, but there will always be some shrinkage with high volume lipofilling and therefore several treatments may be required.

In my case, which implant placement should be preferred; under or over the muscle?

Thank you for your questions.  A dual plane breast augmentation will provide you with the implant beneath the muscle for muscle coverage with all the benefits, but without significant animation deformity.  I properly done dual plane breast augmentation leaves the inferior edge of the pectoralis muscle open which minimizes the animation deformity.  Find an experienced board certified plastic surgeon.

Under or over the muscle

Hi, this is a good question and one that is asked very often.  It is not unusual to get different opinions as all doctors have their own experience and there is often no right or wrong.  You are right in pointing out that there can be issues such as animation deformity when under the muscle, but there is more risk of being able to see the implant if it is on top of the muscle.There is no substitute for an in person consultation, but based on the photograph, it looks like you may have enough tissue to cover the implants, in which case you could have them on top of the muscle.  It can depend on whether you have silicone or polyurethane covered implants and it may depend on the size of the implants that you are looking for, so you would really need a consultation to get a comprehensive opinion.I have put a link to my webinar where I talk about the issues when choosing what plane to put the implant as well as other things, so feel free to check that out.  Good luck.

Breast Augmentation/Breast Implants/Anatomic Gummy Bear Implants/ Silicone Implants/Breast Implant Revision

I appreciate your question.

The best way to determine implant size is based on chest wall measurements that fit your body.  Once we determine that we can choose the profile based on what you want or need to achieve.  

Implants under the muscle, there is less risk of capsular contracture.  Anatomic implants tend to give a more natural shape with more nipple projection.

The best way to assess and give true advice would be an in-person exam.  Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.

Best of luck!Dr. Schwartz

Board Certified Plastic Surgeon



These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.