Dr Scott J Turner | Specialist Plastic Surgeon (FRACS) | Sydney
The implant placement question comes up at almost every breast augmentation consultation, and patients usually arrive with at least some research already done. Often that research has surfaced strong opinions in different directions, and the differences between them can be confusing. Over the muscle, under the muscle, dual plane: each has its uses, each has trade-offs, and the right answer for one patient isn’t always the right answer for another.
I’m Dr Scott J Turner, a Specialist Plastic Surgeon (FRACS), consulting at Bondi Junction in the Eastern Suburbs and Manly on the Northern Beaches. Over a decade in private practice and more than 1,000 breast procedures performed mean placement recommendations come from real clinical experience, not textbook generalisations. For the main procedure page, see breast augmentation in Sydney. Every breast augmentation I perform is carried out at an accredited Sydney private hospital with a specialist anaesthetist. What follows walks through the three main placement options, what each does well, where each falls short, and the clinical factors that drive the recommendation in any given consultation.
The Three Main Placement Options
Quick framing before going further. The implant has to sit somewhere in the breast, and there are three layers of tissue that can hold it: the breast tissue itself, the chest muscle (pectoralis major), or some combination of the two. Each option creates a different anatomical relationship between the implant and the surrounding tissue, and that relationship affects everything from how the breast looks at rest to how it behaves during movement and ageing.
The three options are:
- Subglandular (over the muscle): the implant sits between the breast tissue and the chest muscle
- Submuscular (under the muscle): the implant sits underneath the chest muscle
- Dual plane: the upper portion of the implant sits under the muscle, the lower portion sits behind breast tissue alone
Honest framing: dual plane is used in the majority of modern breast augmentation cases. Subglandular and pure submuscular are used for specific clinical reasons, but they’re the exception rather than the default. The reasons why are worth understanding properly.
Subglandular (Over the Muscle)
The implant sits between the breast tissue and the chest muscle, with no muscle covering it.
What it looks like
The implant takes the shape of the breast tissue draping over it. For patients with good native breast tissue volume, this can produce a soft, mobile result that moves with body movement.
Where it works
- Patients with adequate native breast tissue to cover the implant
- Patients who want to avoid muscle-related considerations (animation deformity during chest exercises)
- Some athletes or bodybuilders whose chest muscle work would distort a submuscular placement
Where it falls short
- Visible implant edges in patients with thin tissue coverage. Without muscle to soften the upper pole, the implant edge can be palpable or visible
- Capsular contracture rates are slightly higher than with submuscular placement
- Mammogram interference. Implants placed over the muscle can obscure more breast tissue on screening mammograms than submuscular implants
- Long-term ptosis. The breast tissue plus implant weight all bears on the skin envelope, which can accelerate sagging over time
- Rippling visibility, particularly with thinner tissue coverage and saline implants (less of an issue with modern cohesive silicone gel)
Honest assessment
In contemporary practice, pure subglandular placement is used in a smaller proportion of cases than it was 15 to 20 years ago. The clinical factors that pushed the field toward dual plane placement (better long-term shape, lower capsular contracture rates, better mammogram visibility) have made subglandular a niche option rather than a default. It still has its place, but the place is narrower than it once was.
Submuscular (Under the Muscle)
The implant sits underneath the pectoralis major muscle, with the muscle covering it across the upper portion of the breast.
A note on what “under the muscle” really means
This is worth clarifying because the terminology can mislead. Full submuscular coverage isn’t really anatomically achievable in breast augmentation. The pectoralis major muscle doesn’t extend across the full lower pole of the breast. It originates from the chest wall and inserts along the upper humerus, but it doesn’t cover the inferior portion of the breast where the breast tissue meets the chest wall at the inframammary fold. So when patients ask about “under the muscle” placement, what they’re really asking about is a partial submuscular placement where the muscle covers the upper portion and the lower portion sits in a subglandular position by anatomical necessity. This is the foundation that dual plane builds on, which is why the two terms get used interchangeably in patient conversations even though they describe slightly different surgical techniques.
What it looks like
The muscle provides extra coverage at the upper pole, which softens the transition from chest to breast and reduces visible implant edges. The result tends to look more rounded at the upper pole, particularly in patients with thin tissue coverage.
Where it works
- Patients with thin native breast tissue who need additional coverage at the upper pole
- Patients seeking a more conservative upper pole appearance rather than visible projection
- Reconstructive scenarios after mastectomy
- Patients with personal or family history of breast cancer where mammographic clarity matters
Where it falls short
- Animation deformity. When the chest muscle contracts during exercise (push-ups, bench press, certain yoga poses), it can distort the implant, causing visible flexing or movement of the breast. This is more common with pure submuscular than with dual plane
- Higher position initially. Implants placed entirely under the muscle can sit higher on the chest immediately after surgery, with a longer settling period
- Lower pole projection limited. The muscle holds the lower portion of the implant against the chest wall, which can limit the drape into the lower pole
- Recovery is slightly more involved. The muscle work means more discomfort in the first 1 to 2 weeks compared to other placements
Honest assessment
Pure submuscular placement is still used, but mostly in specific clinical situations rather than as a default. The animation deformity issue and the limited lower pole drape are the main reasons most surgeons have moved toward dual plane for the majority of cases.
Dual Plane
The upper portion of the implant sits under the muscle, the lower portion sits behind breast tissue alone. The breast tissue can drape over the lower pole, while the muscle still provides coverage and softening at the upper pole.
What it looks like
The combination of muscle coverage at the top and tissue-only coverage at the bottom produces a result that’s typically described as more proportioned than either subglandular or pure submuscular. The upper pole is softened by muscle, the lower pole has drape, and the transitions look continuous rather than abrupt.
Where it works
- The majority of breast augmentation patients with adequate or moderate tissue coverage
- Patients with mild ptosis where the lower pole tissue benefits from being able to drape over the implant. Dual plane can address modest lower pole laxity without requiring a separate lift component, which is part of why it’s so commonly used
- Patients seeking the balance of coverage and shape that dual plane is designed to provide
- Combined breast lift with implants surgery (the standard placement choice in combined cases)
A clarification on the ptosis question. Dual plane is helpful for mild lower pole laxity or modest deflation, but it does not replace a breast lift when significant ptosis is present. When nipple position has descended below the inframammary fold or there’s substantial skin excess, a breast lift with implants is the appropriate procedure, not dual plane alone. The threshold between “dual plane handles it” and “you need a lift component” is a clinical judgement made at consultation, not something you can self-diagnose from photos online.
Where it falls short
- Some animation deformity remains. Less than pure submuscular, but still present in many patients during chest muscle activation
- Surgical complexity. Dual plane requires more careful technique than the simpler subglandular approach. Surgeon experience matters
- Thin tissue patients still need careful planning. Dual plane provides good upper pole coverage, but extremely thin tissue may still benefit from a more conservative implant size or a different approach
The variations
Dual plane isn’t a single technique. There are levels (Dual Plane I, II, and III) that differ in how much the muscle is released from the breast tissue at the lower pole. The variation chosen depends on the patient’s specific anatomy:
- Dual Plane I: minimal release. Used for patients with tight, well-supported breast tissue and minimal lower pole laxity. The muscle and breast tissue attachments at the lower pole are largely preserved
- Dual Plane II: moderate release. Used for patients with mild ptosis, some lower pole laxity, or where the breast tissue needs to drape slightly over the implant lower pole
- Dual Plane III: extensive release. Used for patients with more significant lower pole tissue laxity or a longer-bodied breast shape where the lower pole needs to expand more freely
The right variation for any given patient depends on the clinical findings at consultation: the relationship between nipple position, inframammary fold position, breast tissue distribution, and skin elasticity. This is one of the variables that doesn’t get decided until clinical examination is complete.
Honest assessment
Dual plane is used in the majority of contemporary breast augmentation cases for good reasons. It addresses the limitations of both pure subglandular and pure submuscular placement while keeping the advantages of each. For most patients with reasonable tissue coverage, it’s the placement that produces the most consistent long-term results.
How Placement Interacts with Implant Size, Profile, and Shape
Placement isn’t a standalone decision, and it isn’t a substitute for getting implant sizing right. An implant that’s too wide for your breast base width remains too wide regardless of whether it’s placed dual plane, fully submuscular, or subglandular. Patients sometimes hope that a particular placement will solve a sizing problem, and it won’t.
What this means in practice:
- Implant width still needs to fit your natural breast base width. Placement choice is downstream of width fit, not upstream of it
- Profile decisions sit alongside placement, not after it. High profile, moderate profile, and extra-high profile implants project differently from the chest wall, and that projection interacts with how the placement looks
- Larger implants stretch tissue more, regardless of placement. Going dual plane doesn’t compensate for an implant size that’s beyond what your tissue envelope can comfortably support over time
- Round and anatomical implants both work in dual plane placement. Anatomical (teardrop) implants require closer attention to pocket control and the small but real risk of rotation, but they aren’t ruled out by dual plane placement
- Implant surface choice (smooth vs textured) is a separate decision influenced by considerations like long-term capsular contracture risk and BIA-ALCL risk profile
For more on the implant dimensions side of the decision, see the breast implant size, shape and profile guide and the round vs teardrop breast implants guide. The size, profile, shape, surface, and placement decisions all need to fit together. Picking one in isolation and hoping the rest sorts itself out doesn’t produce the most consistent results.
How the Decision Gets Made
The placement recommendation isn’t picked off a chart. It comes from clinical assessment of several factors specific to each patient.
Native tissue coverage. How much breast tissue do you have to cover an implant? Thicker tissue allows more placement options. Thinner tissue pushes toward submuscular or dual plane for upper pole coverage.
Skin quality and elasticity. Loose skin or stretch marks suggest the skin envelope may not support implant weight well, which influences both placement choice and implant size.
Existing breast shape. Mild ptosis often does well with dual plane (the lower pole drape is part of the technique). Significant ptosis may need a lift component combined with the augmentation, which changes the placement conversation.
Lifestyle and exercise. Chest-engaging exercise (weight training, certain sports, intensive yoga) is more compatible with subglandular than with submuscular. Dual plane sits between the two on this question.
Personal and family history. Breast cancer screening considerations, specific medical conditions, and previous breast surgery all factor into the discussion.
What you’re trying to achieve. Conservative upper pole versus more visible projection, very subtle look versus more obviously augmented, mobile feel versus more stable feel: your goals shape the placement choice as much as the anatomy does.
What I’m assessing in clinic is the overall picture rather than any one factor. Two patients can have similar tissue coverage but different lifestyle factors and end up with different placement recommendations. The two-consultation framework gives time to discuss the recommendation, ask follow-up questions, and arrive at the right decision rather than having one made on the spot.
What About Subfascial Placement?
A fourth option exists that’s worth mentioning briefly. Subfascial placement positions the implant just beneath the fascia (a thin layer of connective tissue) covering the chest muscle, but above the muscle itself. The fascia provides a small amount of additional coverage compared to pure subglandular without the animation deformity issues of submuscular.
In honest practice, subfascial placement is used relatively rarely. The clinical advantages over dual plane are modest, and most surgeons who would consider subfascial typically end up using dual plane instead because the long-term outcomes are more predictable. It’s a real option, but it’s not a major part of contemporary breast augmentation practice.
Animation Deformity in More Detail
Worth a dedicated section since it’s the most-discussed downside of muscle-involving placements.
Animation deformity refers to the visible distortion that can happen when the chest muscle contracts over an implant placed beneath it. The muscle pulls on the implant, causing the breast to flex, dimple, or move in unusual ways during certain activities.
When does it happen?
- Push-ups, bench press, dumbbell flies
- Some yoga poses (chaturanga, plank variations)
- Pectoral flexing
- Some hugging or arm movements (less commonly)
Most patients in everyday life rarely notice animation deformity. It tends to be most visible during activities specifically engaging the chest muscle. For patients whose lifestyle doesn’t involve significant chest-engaging exercise, animation deformity is often a non-issue. For patients who lift weights regularly or do high-impact training, it can be more noticeable and bothersome.
How to manage it:
- Subglandular placement avoids it entirely. This is one of the genuine advantages of subglandular for patients whose lifestyle makes muscle-involving placement impractical
- Dual plane reduces it compared to pure submuscular but doesn’t eliminate it
- Implant choice matters. Smaller implants tend to show less animation deformity than larger ones. Smooth implants behave slightly differently from textured implants on this metric
- Surgical technique matters. Careful muscle release at appropriate levels reduces but doesn’t eliminate the issue
For patients deeply concerned about animation deformity, the consultation conversation includes whether subglandular placement is appropriate for their specific anatomy and goals.
Frequently Asked Questions
What is the most common breast implant placement used today?
Dual plane placement is used in the majority of contemporary breast augmentation cases. The technique places the upper portion of the implant under the chest muscle for coverage at the upper pole, while the lower portion sits behind breast tissue alone for drape at the lower pole. Most patients with reasonable tissue coverage are good candidates for dual plane, though specific clinical situations may call for subglandular or pure submuscular placement instead.
Is dual plane the same as under the muscle?
Not quite, and the distinction matters. “Under the muscle” is often used loosely in patient conversations to mean any placement that involves the pectoralis major. Anatomically, full submuscular coverage isn’t really achievable in breast augmentation because the pectoralis major muscle doesn’t extend across the full lower pole of the breast. Most “under the muscle” placements are in reality partial submuscular, where the muscle covers the upper portion and the lower portion sits subglandular by anatomical necessity. Dual plane is the refined, deliberate version of that approach, with controlled muscle release at the lower edge to allow the lower implant pole to sit behind breast tissue cleanly.
Can I have implants placed over the muscle?
Yes, in appropriate clinical situations. Subglandular placement (over the muscle) suits patients with adequate native breast tissue coverage who want to avoid muscle-related considerations like animation deformity during exercise. The trade-offs include slightly higher capsular contracture rates, more visible implant edges in patients with thin tissue, and some interference with mammographic screening compared to submuscular placement.
What is animation deformity and is it permanent?
Animation deformity is the visible distortion that can occur when the chest muscle contracts over an implant placed beneath it. It happens during activities that engage the pectoralis major muscle, like push-ups or bench press. The deformity is only present during muscle contraction, returning to baseline when the muscle relaxes. Subglandular placement avoids it entirely. Dual plane reduces but does not eliminate it compared to pure submuscular placement.
Which implant placement option lasts the longest?
All three placement options can produce long-lasting results, with most patients keeping their implants for 15 to 20 years or longer. The factors that affect long-term outcome are more about implant care, weight stability, pregnancy, breastfeeding, and supportive bra wear during exercise than about which placement was used. Dual plane and submuscular tend to maintain better upper pole shape over time than subglandular, which is one of several reasons they’re more commonly used in contemporary practice.
Consult with Dr Scott J Turner in Sydney
Dr Scott J Turner is a Specialist Plastic Surgeon (FRACS) consulting at his Bondi Junction (Eastern Suburbs) and Manly (Northern Beaches) clinics in Sydney. Surgery is performed at accredited private hospitals in Sydney, including Bondi Junction Private Hospital, Delmar Private Hospital in Dee Why, and East Sydney Private Hospital.
Every consultation is conducted personally by Dr Turner. There are no patient representatives or coordinators standing in for the surgeon. Under the Medical Board of Australia’s cosmetic surgery framework introduced on 1 July 2023, the consultation pathway includes a GP referral before the first surgical consultation, two consultations with the surgeon minimum, a seven-day cooling-off period after informed consent before surgery can be booked, and a $1,000 surgical deposit payable only after the second consultation, not before. The placement conversation gets real time at consultation, including detailed clinical examination, discussion of how the placement options interact with your specific anatomy and goals, and honest assessment of the trade-offs each option carries for your situation.
If you’re considering breast augmentation surgery, the next step is to obtain a GP referral and book an initial consultation. Contact the practice on 1300 437 758 or email [email protected] to begin the process. For more detail on the procedure itself, see the breast augmentation procedure page.
General information only, not medical advice. Implant placement choice varies between patients based on individual anatomy, lifestyle, and goals, so any decision about breast augmentation requires individual clinical assessment by a qualified health practitioner.
