The Placement Decision and Why It Matters
When a breast implant is placed, it lives in a pocket — a surgically created space between tissue layers. The two primary options are submuscular placement (beneath the pectoralis major muscle, commonly called "under the muscle") and subglandular placement (above the muscle but below the breast gland, commonly called "over the muscle"). A third option — dual-plane — is a refinement of submuscular placement that has become the most commonly used technique at experienced practices.
This is not a patient preference decision in the way that implant size or shape might be. Placement plane is a clinical decision that depends on your anatomy, breast tissue thickness, body composition, and the desired outcome. A patient who insists on subglandular placement when she has minimal tissue coverage is making an anatomically poor choice. Conversely, a patient with significant existing breast tissue who needs over-muscle placement for specific reasons shouldn't be forced into a submuscular pocket. The right recommendation emerges from a physical examination and a discussion of your goals.
Under vs. Over Muscle: The Trade-offs
- More tissue coverage — better concealment of implant edges and rippling
- More natural appearance in thin patients with minimal breast tissue
- Lower capsular contracture rates (muscle provides compression and movement)
- Better mammography visualization — muscle displaces implant during compression
- Less palpable upper pole — softer transition from chest to breast
- More initial discomfort — pectoralis muscle is elevated and heals over 4–6 weeks
- Longer recovery before return to upper body exercise
- Animation deformity — implant may move with muscle flexion (usually minor)
- Requires more surgical dissection
- Faster, less painful recovery — muscle not disturbed
- No animation deformity with muscle contraction
- Better lower pole fill in patients with existing breast tissue
- Appropriate for patients with significant ptosis who need sub-glandular for lift effect
- Shorter operative time
- More visible rippling and palpable edges — especially in thin patients
- Higher capsular contracture rate than submuscular
- Less natural upper pole appearance in thin patients
- Mammography more technically difficult — implant overlies breast tissue
Dual-Plane: The Most Common Technique
Dual-plane placement is a modification of submuscular augmentation that is used in the majority of breast augmentations at this practice. In dual-plane, the upper pole of the implant is covered by the pectoralis muscle (gaining the coverage and contracture-rate benefits of submuscular placement), while the lower pole of the implant lies in a subglandular position (allowing better lower pole fill and a more natural inferior breast contour). For more on how placement affects scar-tissue risk, see Capsular Contracture: Signs, Prevention & Treatment in NJ.
The degree of muscle release — how much of the inferior muscle origin is divided — determines whether the result is a Type I, II, or III dual-plane. Type I involves minimal muscle release and is used when breast gland position is good. Type III involves more release and is used when the gland needs to redrape over the lower pole of the implant for the best result. This technical nuance is why "under the muscle" is not a single fixed procedure but a spectrum tailored to each patient's anatomy. The added muscle coverage of submuscular and dual-plane placement is also one of the best defenses against visible rippling — see Breast Implant Rippling: Causes and Fixes for how placement, implant type, and fat grafting each reduce it.
"In the vast majority of my patients, dual-plane submuscular placement is the right answer — it provides the coverage benefits of going under the muscle while allowing the natural lower pole contour that fully submuscular placement can restrict. The exception teaches the rule."
— Dr. Farhad Rafizadeh MD FACS
Detailed Comparison Table
| Factor | Under Muscle | Over Muscle |
|---|---|---|
| Initial Pain / Recovery | More discomfort; 4–6 weeks for muscle to settle | Less discomfort; faster initial recovery |
| Rippling / Palpability | Less — muscle adds a layer of coverage | More — especially visible in thin patients |
| Capsular Contracture Rate | Lower (muscle movement prevents static compression) | Higher in long-term studies |
| Mammography | Easier — implant displaced during compression | More challenging — implant overlies tissue |
| Animation Deformity | Possible — visible with pec flex (usually minor) | None |
| Best For | Thin patients, small starting size, athletes needing less deformity concern | Patients with adequate breast tissue, ptosis, short recovery priority |
| Upper Pole Appearance | Softer, more gradual slope | Fuller, rounder — can look augmented |
| Return to Exercise | 6–8 weeks for full upper body | 3–4 weeks typically |
Incision Location: How You Get There
The implant pocket is accessed through an incision that can be placed in three locations. The choice of incision is separate from the choice of pocket plane but interacts with it.
Inframammary fold (IMF): The most commonly used incision — a 4–5 cm cut in the natural crease beneath the breast. Direct access to both submuscular and subglandular pockets. Scar in the fold is naturally hidden and fades well. Best visualization and control.
Periareolar: Incision along the lower edge of the areola. Hidden in the color transition. Requires adequate areola diameter. Best used for subglandular or dual-plane. Slightly higher capsular contracture rate in some studies (proximity to breast ducts). Can affect nipple sensation in more cases than IMF.
Transaxillary: Incision in the axilla (underarm). No scar on the breast. Requires endoscopic assistance for optimal visualization. Technical limitations make precise pocket control more challenging than IMF. Used in specific scenarios when patients strongly prefer no breast scar and anatomy is appropriate.
The inframammary approach is used in the majority of breast augmentations at this practice because it offers the best visualization, the most precise pocket control, and reliable scar outcomes.
Dr. Rafizadeh performs breast augmentation and implant placement consultations at his practice in Morristown, NJ, serving patients from Morris County, Essex County, Bergen County, and Union County. Women from Short Hills, Summit, Parsippany, Chatham, Livingston, Madison, Montclair, and throughout North Jersey consult with him on submuscular vs. subglandular placement — a decision he tailors to each patient's tissue thickness, activity level, and aesthetic goals. Patients from New York City also travel to his Morristown office for this level of individualized surgical planning.