Above or below the muscle?

Neither the position above the muscle nor below it is inherently the superior choice. Each addresses different anatomical starting points more or less effectively — and the decision should be made individually, not according to a general rule.

What Does "Above the Muscle" Mean?

In the subglandular position, the implant is placed between the existing breast tissue and the pectoralis major muscle beneath it. This position generally follows the natural shape of the breast closely, since the muscle itself isn't involved and the implant sits directly beneath the skin and glandular layer.

For patients with sufficient existing tissue, this position can allow for softer, more natural implant movement, since the pectoral muscle above doesn't affect the shape with every contraction. It tends to be less suitable when very little existing tissue is present, since the implant then sits closer to the skin surface, and contours or edges can become more visible or palpable.

What Does "Below the Muscle" Mean?

In the submuscular or dual-plane position, the implant is placed entirely or partially beneath the pectoralis major. In a fully submuscular position, the implant sits completely under the muscle; in the more commonly used dual-plane technique today, the muscle is left covering the implant in the upper portion but partially released lower down, so the lower glandular tissue sits more directly over the implant.

The additional layer of muscle over the implant can, for patients with little existing tissue, provide a softer contour and a more natural transition in the upper breast, since the muscle further covers the implant edges.

Why Existing Tissue Shapes the Decision

How much of a patient's own breast tissue is present is one of the most important factors in choosing implant position. With sufficient glandular and fatty tissue, subglandular placement can provide good implant coverage without needing the additional protection of muscle. In very slender patients with little existing tissue, the additional coverage from the muscle can instead help make implant edges less visible or palpable, particularly in the upper breast.

That doesn't mean a subglandular position is categorically ruled out with little tissue, or that a submuscular position is automatically unnecessary with plenty of tissue — it means this trade-off has to be part of individual planning rather than following a fixed rule.

Beyond the sheer amount of tissue, skin quality plays a role too. How visible or palpable implant edges become depends not only on whether the muscle provides additional coverage, but also on how thin or elastic the skin itself is. A related phenomenon is so-called rippling — visible or palpable folds on the implant surface, which can occur more readily with very thin skin and little existing tissue, regardless of whether the implant sits above or below the muscle. Here, too, implant position can make a difference, but it's only one of several factors that together determine the outcome.

Why Sport Matters So Much in This Decision

An often-underestimated but genuinely decisive factor is individual physical activity, particularly strength training. In a submuscular or dual-plane position, contraction of the pectoral muscle — during bench press or similar exercises — can cause a visible, usually temporary distortion or shift in the breast, an effect known as animation deformity. At rest, the breast can look entirely harmonious; only when the muscle is engaged does the change appear.

How pronounced this effect is depends strongly on the extent of physical activity. A patient who occasionally jogs or practices yoga has different considerations than a competitive athlete, a CrossFit practitioner, or a bodybuilder with a well-developed pectoral muscle, where contraction is markedly stronger and more frequent. For some patients, animation deformity plays essentially no role in daily life; for others, it can be bothersome enough to meaningfully influence the decision.

At the same time, this can't be reduced to a simple rule. The same very slender, athletically active patient can also have very little existing breast tissue — meaning the additional muscle coverage would actually offer advantages from a tissue standpoint, even though the same muscle activity argues against a submuscular position from a training standpoint. Being athletic, then, doesn't automatically mean "above the muscle," and being slender doesn't automatically mean "below the muscle" — both factors have to be weighed against each other for the individual patient, not addressed one after the other as separate checkboxes.

What Matters for Mammography and Medical Imaging

Another practical consideration involves future imaging, such as routine mammography screening. Implants placed below the muscle can, with certain imaging techniques, tend to allow somewhat better visualization of the breast tissue behind them, since the implant and glandular tissue are more clearly separated by the muscle.

This doesn't mean a subglandular position fundamentally prevents adequate mammography — specialized techniques can adequately image both implant positions. Still, this is one reason some physicians raise future screening during consultation, particularly for patients with a family history relevant to breast health.

Is One Position Inherently Safer Than the Other?

This common claim is also too broad. Both implant positions have specific trade-offs, but neither is inherently the safer choice. Which risks are relevant in an individual case depends on several factors and should be discussed in personal consultation — a position shouldn't be chosen because it's generally described as "safer" or "more modern," but because its concrete advantages are relevant to the particular patient and its trade-offs are acceptable to her.

Why Surgeons Have Different Preferences

There isn't only one way that works in breast surgery. Surgeons build experience with particular techniques over years and develop their own approaches from that experience — which isn't inherently a problem. What matters is that the technique isn't chosen independently of the individual patient.

A good consultation explains not just which position is being chosen, but why — not "this is how I always do it," but a rationale specific to the anatomy in question. This distinction is a good measure of how individualized a consultation actually is.

Why There's No Fundamentally Superior Position

The choice between subglandular and submuscular position can't be settled in general favor of one or the other. Each has clear advantages in certain anatomical and personal situations, and equally clear limitations in others. A slender patient with very little existing tissue who trains intensively faces a different trade-off than a patient with more existing tissue and little upper-body athletic activity — and both can arrive at a result that suits them with different positions.

Conclusion

Neither the position above nor below the muscle is fundamentally the better or safer choice. Existing tissue, skin quality, individual imaging priorities, and above all the extent and type of physical activity together determine which position makes sense for a given patient. A good consultation explains both concepts, their respective strengths and limitations, and grounds the recommendation specifically in individual anatomy and lifestyle — not in a blanket rule about which position is generally superior.

Alongside implant position, implant size is one of the other most common questions in consultation — read more in our article "How Big Is Too Big?"

To learn more about our approach, visit our Breast Augmentation page, or reach out to arrange a private consultation.

Frequently Asked Questions

Is a position below the muscle inherently more natural than above it?

No. Both positions can produce a natural result with suitable anatomy. Which position is more appropriate depends on existing tissue, skin quality, and individual priorities.

What is the dual-plane technique?

A variant of the submuscular position in which the muscle is left covering the implant in the upper portion but partially released lower down, so the lower glandular tissue sits more directly over the implant.

Does strength training affect the choice of implant position?

Yes, significantly. In a submuscular position, contraction of the pectoral muscle can cause a visible, usually temporary distortion of the breast (animation deformity), which matters considerably more with intensive upper-body training than with occasional physical activity.

Is one implant position inherently safer than the other?

No. Both positions have specific, but not fundamentally superior, safety profiles. Which risks are relevant depends on the individual case.

What is rippling?

Visible or palpable folds on the implant surface, which can occur more readily with thin skin and little existing tissue — regardless of whether the implant sits above or below the muscle.

Is mammography easier with implants below the muscle?

Implants below the muscle can, with certain imaging techniques, allow somewhat better visualization of breast tissue. Specialized techniques, however, can adequately image both positions.

Can implant position be changed later?

In certain situations, the implant pocket can be altered as part of a revision procedure. Whether this makes sense and is technically feasible depends on the individual starting point.