The Journal · Breast surgery
Breast implants under or over the muscle: which is better?
The short answer: for most patients the best placement is neither fully under nor fully over the muscle, but a dual plane — the upper implant sits behind the chest muscle while the lower part sits behind the gland. It hides the implant edge and rippling in thin tissue while giving a natural upper-pole slope. Fully over the muscle is reserved for selected cases.
What do “under” and “over” the muscle actually mean?
The two classic options describe where the implant sits relative to the pectoralis muscle across the front of the chest. Over the muscle (subglandular) places the implant between the breast gland and the muscle — directly behind the breast tissue. Under the muscle means the implant is covered by the pectoralis, adding a layer of muscle over the top of the implant.
In practice, a purely submuscular pocket only covers the upper part of the implant well, because the muscle does not extend across the whole lower breast. That is why modern breast augmentation most often uses the dual plane — a refinement of under-the-muscle placement that releases the lower edge of the muscle so the implant sits behind muscle up top and behind gland below.
Why is over-the-muscle placement faster to recover from?
Because the chest muscle is left undisturbed. Nothing is lifted or divided, so early discomfort is usually milder and the return to normal movement can feel quicker. Subglandular placement also avoids animation deformity — the flicker or movement of the implant that can happen when the pectoralis contracts during exercise, since the implant does not sit under the working muscle.
The trade-off is coverage. With the implant sitting directly under the skin and gland, there is less soft tissue to disguise it. In a slim patient, the upper edge of the implant can become visible or palpable, and rippling — fine surface wrinkling — shows more easily. Over time, an implant resting on the gland can also place more downward load on the skin.
Why does under-the-muscle placement look more natural in thin patients?
The layer of muscle over the top of the implant softens the transition from chest to breast, so the upper pole slopes gently instead of showing a defined edge. For anyone whose own breast tissue is thin — which describes many patients seeking a first augmentation — that extra cover is what keeps the result looking like breast rather than implant. It also makes edges and rippling far harder to see or feel.
The classic downsides of going fully under the muscle are more early tightness and the risk of animation with the implant partly under an active muscle. The dual plane approach is designed to keep the coverage benefit while limiting these drawbacks.
Why is dual plane Dr. Michels’ preferred default?
Because it takes the strongest feature of each pocket. The upper implant is tucked behind the pectoralis for a natural, well-covered upper-pole slope and hidden edges; the lower implant sits behind the gland so the breast fills out and settles naturally into its lower curve. In a thin chest this combination gives the most reliably natural result, which is why it is the right choice for the large majority of patients.
Dr. Paulo Michels places implants through an inframammary incision in the breast crease, using round, smooth implants, and tailors how far the muscle edge is released to each patient’s tissue. Fully subglandular placement is kept for selected cases — for example a patient with ample natural cover who wants to avoid any animation, or particular anatomy discussed at consultation. It is a considered exception, not the routine.
The honest version
It is rarely all-or-nothing
“Under or over the muscle” sounds like a single either/or decision, but the answer that suits most people is the middle path. Dual plane gives thin tissue the coverage it needs up top while letting the lower breast settle naturally — and the final call is always made on your own anatomy at examination, not from a chart.
Which placement is right for me?
It comes down to how much breast tissue you already have and what matters most to you:
- Thin cover, want the most natural upper pole: dual plane is almost always the answer — muscle hides edges and rippling.
- Plenty of natural tissue and keen to avoid animation: subglandular may be considered in selected cases.
- Very active in the gym or competitive sport: worth discussing animation trade-offs directly, as pectoral movement is a factor.
- Some sagging as well as volume loss: the plan may combine placement with a lift, assessed individually.
Dr. Paulo Michels examines and operates at Elyzee Hospital in Abu Dhabi, treating patients from both Abu Dhabi and Dubai. Cost depends on factors such as implant choice, technique and whether other work is combined — discussed transparently at consultation.
Frequently asked questions
Is under-the-muscle placement more painful?
Early tightness and discomfort tend to be a little more noticeable when the muscle is involved, because it has been released to make room for the implant. It typically settles within the first days to weeks, and pain is managed with your recovery plan. Over-the-muscle placement usually feels milder early on.
Which placement gives less rippling?
Under-the-muscle, and dual plane in particular, hides rippling best because the layer of muscle adds cover over the top of the implant. Over-the-muscle placement shows rippling more readily in patients with thin tissue, since only skin and gland lie over the implant.
What is animation deformity?
It is movement or flattening of the breast when the chest muscle contracts, which can occur when an implant sits under an active pectoralis. It is a normal consideration with muscle-based placement and is usually subtle; subglandular placement avoids it because the implant is not under the working muscle.
Can I change placement later?
Placement can sometimes be revised in a further operation if there is a clear reason, but it is more surgery, so the aim is to choose the right plane the first time. That decision is made together at consultation, based on your tissue and your priorities.
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