Breast augmentation comes down to two linked decisions: where the implant sits (under the muscle, over the muscle, or a mix of both) and where the scar goes. Your body type and goals decide the rest.
What Does "Over or Under the Muscle" Actually Mean?
According to the American Board of Cosmetic Surgery (ABCS), an implant can sit under the pectoral muscle (submuscular), directly behind the breast tissue and over the muscle (subglandular), or beneath a thin fascia layer just above the muscle (subfascial).
Why Do Surgeons Put Implants Under the Muscle?
Under-the-muscle placement is the default pick. The ABCS notes that submuscular placement adds soft-tissue coverage – most important for thin women with little natural breast tissue, hiding implant edges and keeping a smooth slope from the chest wall. The implant also interferes less with mammograms, and visible rippling drops because the muscle pads the implant edges – the ABCS notes submuscular placement adds soft-tissue coverage, and thin coverage is what leaves edges visible.
Then there's capsular contracture, the firm, painful tightening of the scar capsule that forms around every implant. It shows up less often behind the muscle: a 2019 meta-analysis of eleven trials, summarized in a 2023 Annals of Translational Medicine review, found 9.6% subglandular versus 1.7% submuscular, though the authors caution the studies varied widely. The theory: the muscle shields the implant from bacteria in the gland, a known driver of contracture.
Recovery tends to take longer and hurt more at first, because the chest muscle has been stretched. Then there's animation deformity: the ABCS describes the implant visibly shifting when you flex your pectoral muscle, most often with subpectoral placement – worth a careful talk-through if you lift weights or train hard, which is why some heavy trainers go over the muscle instead.
When Does "Over the Muscle" Make Sense?
Over-the-muscle placement skips the muscle entirely, so healing is usually faster – the ABCS notes subglandular placement typically involves a shorter recovery time – with no animation deformity, since the muscle never touches the implant.
The catch is coverage: on thin frames, results can look less natural and rippling shows more easily, since the implant sits closer to the skin.
What Is Dual Plane Placement?
Dual plane is the middle ground: the implant sits under the pectoral muscle at the top and middle of the breast, with the lower part free of the muscle.
It's often recommended for women with mild drooping who want a very natural look with extra fullness in the lower breast: the muscle covers where it counts most (the upper pole) while the implant settles more naturally below.
Where Will the Scar Be? The Three Incision Options
Inframammary (breast crease). One of the most popular incisions among patients, according to the American Board of Cosmetic Surgery. The cut runs about two inches along the crease, and the scar hides inside that fold. The ABCS puts the typical length at 2 to 5 centimeters, and the crease can be reopened later for implant exchange or removal.
Periareolar (around the nipple). The cut follows the outer edge of the areola, according to the American Board of Cosmetic Surgery. But the surgeon must tunnel through breast tissue to reach the implant pocket, cutting milk ducts along the way. A meta-analysis found 7.2% contracture with periareolar incisions versus 3.1% with non-periareolar approaches, per the Annals of Translational Medicine review, likely because bacteria from the milk ducts contaminate the implant. It also carries a higher risk of lost nipple sensation than the crease incision – a 2026 scoping review of 37 studies found large cohorts showed about 3x the risk of numbness and pain with periareolar incisions.
Transaxillary (armpit). The incision hides in an underarm crease, so there is no scar on the breast at all. The ABCS notes both saline and silicone implants can go through this opening, though the surgeon works from far away with an endoscopic camera. It's one of the least common approaches – a complex technique that takes specific skill, according to the ABCS.
How Does Your Incision Choice Connect to Placement?
This is the part patients rarely hear: the incision and the placement are not separate choices but one surgical plan.
Every incision shapes what comes next: a large silicone implant risks damage passing through a small areola, and the transaxillary route makes precise submuscular pocket work harder from the side.
There's also a contracture-risk feedback loop: the Deva 14-point plan, a widely cited set of steps for cutting bacterial contamination, recommends inframammary incisions and the submuscular plane whenever possible. So when your surgeon suggests under-the-muscle with a crease incision, it's usually not two separate opinions but one decision.
Who Is a Good Candidate for Each Option?
Women with little natural breast tissue usually get the best result under the muscle, where the extra coverage hides edges and rippling. Women with plenty of breast tissue have more freedom and may do well over the muscle, especially for a quicker recovery.
Heavy lifters should weigh animation deformity seriously. For mild drooping with fullness but no lift, dual plane was designed for you.
For the smallest possible breast scar, the crease incision hides it in shadow. If you cannot tolerate any scar on the breast, the armpit approach exists, but you trade precision for it.
Talk Through Your Options at Renew Me Plastic Surgery
Placement and incision work as a pair, and the right pair depends on your anatomy and activities. A one-on-one surgical plan with a surgeon who has seen each combination heal sorts it out.
Renew Me Plastic Surgery offers consultations in Miami. Dr. Paul Boulos will walk you through placement and incision options for your body and answer every question. Call (786) 957-1777 or visit us at 730 NW 107th Ave, Suite #117, Miami, FL 33172.
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Sources
American Board of Cosmetic Surgery, "The ABCs of Cosmetic Surgery: Breast Augmentation Terms to Know" (placement options, incision types, recovery notes, animation deformity, implant rippling): https://www.americanboardcosmeticsurgery.org/blog/the-abcs-of-cosmetic-surgery-breast-augmentation-terms-to-know/
American Board of Cosmetic Surgery, "Breast Implant Revision" (placement options, animation deformity, submuscular coverage, recovery notes): https://www.americanboardcosmeticsurgery.org/cosmetic-procedures/breast/breast-implant-revision/
Gorgy A et al., "Implant-based breast surgery and capsular formation: when, how and why? – a narrative review," Annals of Translational Medicine, 2023 (Li et al. 2019 meta-analysis: 9.6% subglandular vs 1.7% submuscular capsular contracture; periareolar vs non-periareolar incision contracture rates; Deva 14-point plan): https://dx.doi.org/10.21037/atm-23-131
Tulimat B et al., "Comparing Nipple and Areola Sensory Outcomes and Nerve-Related Complications Using Different Incision Types in Breast Augmentation: A Scoping Review," Aesthetic Plastic Surgery, 2026 (large cohorts showed ~3x higher risk of nipple hypoesthesia and pain with periareolar vs inframammary incisions): https://pubmed.ncbi.nlm.nih.gov/41709017/
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