{"id":23949,"date":"2026-04-17T12:00:00","date_gmt":"2026-04-17T12:00:00","guid":{"rendered":"https:\/\/www.doctoraso.es\/blog\/breast-implants-above-or-below-the-muscle-how-we-choose\/"},"modified":"2026-10-02T08:03:05","modified_gmt":"2026-10-02T08:03:05","slug":"breast-implants-above-or-below-the-muscle-how-we-choose","status":"publish","type":"post","link":"https:\/\/www.doctoraso.es\/en\/blog\/breast-implants-above-or-below-the-muscle-how-we-choose\/","title":{"rendered":"Breast Implants Above or Below the Muscle: How We Choose"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column][vc_column_text]<\/p>\n<article class=\"aso-plane\">\n<header class=\"aso-plane__intro\">\n<div class=\"aso-plane__eyebrow\">Implant placement and results in motion<\/div>\n<p class=\"aso-plane__lead\"><strong>No single placement is best for every patient.<\/strong> When there is enough tissue coverage, placing the implant above the muscle allows the breast to move more freely, avoids distortion when the pectoral muscle contracts, and often makes recovery easier. When tissues are thin or the risk of rippling is greater, coverage beneath the muscle can offer an important advantage.<\/p>\n<div class=\"aso-plane__summary\" aria-label=\"Summary of breast implant placement\">\n<div><strong>Prepectoral<\/strong><span>Subglandular and subfascial: implant above the pectoral muscle<\/span><\/div>\n<div><strong>Submuscular<\/strong><span>Includes complete coverage and dual plane, or partial coverage<\/span><\/div>\n<div><strong>An individual decision<\/strong><span>Coverage, pinch test, sagging, implant, activity, and priorities<\/span><\/div><\/div>\n<\/header>\n<section class=\"aso-plane__answer\" aria-labelledby=\"respuesta-encima-debajo-musculo\">\n<h2 id=\"respuesta-encima-debajo-musculo\">Is it better to place breast implants above or below the muscle?<\/h2>\n<p><strong>Above the muscle can be the most natural option when there is enough tissue to cover the implant adequately.<\/strong> The breast moves more freely, does not distort when the pectoral muscle contracts, and surgery is usually less painful. We prefer placement below the muscle when coverage is limited, the edge could be visible or palpable, or the risk of rippling is greater.<\/p>\n<p>In our practice, the term <strong>submuscular<\/strong> includes both complete submuscular placement and <strong>dual plane<\/strong>techniques, in which the muscle mainly covers the upper part of the implant. We almost never use complete muscular coverage: we usually perform at least a dual plane I, releasing the lower attachments of the pectoral muscle.<\/p>\n<\/section>\n<details class=\"aso-plane__toc\">\n<summary>Article contents<\/summary>\n<nav aria-label=\"Contents: implants above and below the muscle\">\n      <a href=\"#anatomia\">Which tissues cover an implant<\/a><br \/>\n      <a href=\"#comparativa\">A quick comparison of placements<\/a><br \/>\n      <a href=\"#prepectoral\">Implants above the muscle<\/a><br \/>\n      <a href=\"#subglandular\">Subglandular placement<\/a><br \/>\n      <a href=\"#subfascial\">Subfascial placement<\/a><br \/>\n      <a href=\"#submuscular\">Submuscular implants<\/a><br \/>\n      <a href=\"#dual-plane\">Dual plane I, II, and III<\/a><br \/>\n      <a href=\"#mama-dinamica\">Why breast movement matters<\/a><br \/>\n      <a href=\"#eleccion\">How we choose the placement<\/a><br \/>\n      <a href=\"#ptosis\">Sagging, breast lift, and waterfall deformity<\/a><br \/>\n      <a href=\"#evidencia\">What the evidence says<\/a><br \/>\n      <a href=\"#preguntas\">Frequently asked questions<\/a><br \/>\n    <\/nav>\n<\/details>\n<section class=\"aso-plane__section\" id=\"anatomia\">\n<div class=\"aso-plane__label\">Essential anatomy<\/div>\n<h2>Which tissues lie between the skin and the pectoral muscle?<\/h2>\n<p>To understand where an implant is placed, it helps to think of the breast in layers. From the surface inward, there are the skin, fat, breast gland, a very thin fascia covering the pectoral muscle, the pectoralis major muscle, and, behind it, the chest wall.<\/p>\n<p>The implant can lie in front of the pectoral muscle\u2014prepectoral placement\u2014or be covered completely or partly by it\u2014submuscular placement. The amount and quality of tissue in front of the implant influence how easily it can be felt, how visible its edge is, and the risk of folds or rippling.<\/p>\n<figure class=\"aso-plane__figure aso-plane__figure--diagram\">\n      <img src=\"https:\/\/www.doctoraso.es\/wp-content\/uploads\/2026\/10\/implant-plane-anatomy-en-2026.jpg\" alt=\"Diagram of the layers of an unoperated breast: skin, fat, gland, and pectoral muscle\" width=\"800\" height=\"644\" loading=\"lazy\" decoding=\"async\"><figcaption>Diagram of an unoperated breast. The fascia is a thin covering over the pectoral muscle; it is not equivalent to a layer of muscle.<\/figcaption><\/figure>\n<\/section>\n<section class=\"aso-plane__section\" id=\"comparativa\">\n<div class=\"aso-plane__label\">An overview<\/div>\n<h2>Subglandular, subfascial, and submuscular: the main differences<\/h2>\n<p>There are two broad groups. In <strong>prepectoral<\/strong>placements, the implant lies above the muscle; these include subglandular and subfascial placement. In <strong>submuscular<\/strong>placements, the pectoral muscle covers the whole implant or, much more commonly, only part of it using a dual plane technique.<\/p>\n<div class=\"aso-plane__table-wrap\" role=\"region\" aria-label=\"Comparison of implant placements\" tabindex=\"0\">\n<table class=\"aso-plane__table\">\n<thead>\n<tr>\n<th>Placement<\/th>\n<th>Where it sits<\/th>\n<th>Main advantage<\/th>\n<th>Main limitation<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<th scope=\"row\">Subglandular<\/th>\n<td>Beneath the gland and above the pectoral muscle<\/td>\n<td>Natural movement, no muscular animation, and faster recovery<\/td>\n<td>Needs sufficient coverage to avoid visible edges or rippling<\/td>\n<\/tr>\n<tr>\n<th scope=\"row\">Subfascial<\/th>\n<td>Beneath the fascia and above the pectoral muscle<\/td>\n<td>Avoids movement-related distortion, like subglandular placement<\/td>\n<td>The fascia is very thin and, in our experience, adds very little useful coverage<\/td>\n<\/tr>\n<tr>\n<th scope=\"row\">Complete submuscular<\/th>\n<td>Implant completely covered by muscle<\/td>\n<td>Maximum muscular coverage<\/td>\n<td>More pain, an initially high implant position, and less natural movement<\/td>\n<\/tr>\n<tr>\n<th scope=\"row\">Dual plane<\/th>\n<td>Upper part beneath the pectoral muscle, with the lower part in contact with the gland<\/td>\n<td>Combines upper coverage with better expansion of the lower pole<\/td>\n<td>Can cause animation and takes longer to recover from than prepectoral placement<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n<aside class=\"aso-plane__note\">\n<h3>The table provides guidance, not a decision<\/h3>\n<p>The same placement can be excellent for one patient and unsuitable for another. Tissue thickness, chest shape, implant size, pectoral activity, sagging, and skin quality matter more than a rigid preference for being \u201cabove\u201d or \u201cbelow.\u201d<\/p>\n<\/aside>\n<\/section>\n<section class=\"aso-plane__section\" id=\"prepectoral\">\n<div class=\"aso-plane__label\">Above the muscle<\/div>\n<h2>What does prepectoral implant placement mean?<\/h2>\n<p>Prepectoral means the implant is placed in front of the pectoralis major without using the muscle as coverage. It can lie directly beneath the gland\u2014subglandular\u2014or beneath the pectoral fascia\u2014subfascial.<\/p>\n<p>Both allow the implant to follow the breast&#8217;s natural movements without being pulled by pectoral contraction. They also avoid muscle dissection, so pain and recovery are usually reduced. A retrospective study of primary augmentation found a shorter duration of pain and faster recovery in the subglandular group than in the subpectoral group, although patients were not randomly allocated. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/26770489\/\" target=\"_blank\" rel=\"noopener\">Read the study on PubMed<\/a>.<\/p>\n<div class=\"aso-plane__practice\">\n<div>\n        <span>Our current clinical practice<\/span><br \/>\n        <strong>\u226560 %<\/strong><\/p>\n<p>Prepectoral placements currently account for at least 60% of our primary breast augmentations.<\/p>\n<\/p><\/div>\n<div>\n        <span>Breast lift with implants<\/span><br \/>\n        <strong>\u224810 %<\/strong><\/p>\n<p>We use prepectoral placement in approximately 10% of breast lifts with implants.<\/p>\n<\/p><\/div><\/div>\n<p class=\"aso-plane__data-note\">These are approximate internal figures from our current practice, not trial results or a recommendation that applies to every clinic.<\/p>\n<\/section>\n<section class=\"aso-plane__section\" id=\"subglandular\">\n<h2>Subglandular implants: above the muscle and beneath the breast<\/h2>\n<p>In subglandular placement, the implant lies immediately behind the breast gland and in front of the pectoral muscle. We use it in traditional <a href=\"https:\/\/www.doctoraso.es\/en\/breast-augmentation-in-madrid\/\">breast augmentation<\/a> when coverage is sufficient, and always in our mia\u00ae and Preserv\u00e9&#x2122; procedures.<\/p>\n<figure class=\"aso-plane__figure aso-plane__figure--diagram\">\n      <img src=\"https:\/\/www.doctoraso.es\/wp-content\/uploads\/2026\/10\/implant-plane-subglandular-en-2026.jpg\" alt=\"Diagram of a subglandular breast implant above the pectoral muscle\" width=\"800\" height=\"640\" loading=\"lazy\" decoding=\"async\"><figcaption>A subglandular implant: beneath the gland and above the pectoral muscle.<\/figcaption><\/figure>\n<div class=\"aso-plane__pros-cons\">\n<article class=\"aso-plane__pros\">\n<h3>Advantages<\/h3>\n<ul>\n<li>Does not cause breast distortion when the pectoral muscle contracts.<\/li>\n<li>Allows the implant to follow breast movement more naturally.<\/li>\n<li>Surgery is usually less painful and recovery is faster.<\/li>\n<li>Avoids a relatively fixed, high implant becoming separated from a gland that descends over time.<\/li>\n<li>Can feel very natural with ergonomic implants and adequate coverage.<\/li>\n<\/ul>\n<\/article>\n<article class=\"aso-plane__cons\">\n<h3>Limitations<\/h3>\n<ul>\n<li>In very thin patients, the implant edge may be visible or palpable.<\/li>\n<li>Insufficient coverage increases the risk of visible rippling.<\/li>\n<li>An implant that is too large or wide can stretch tissues that do not provide sufficient support.<\/li>\n<li>It is unsuitable if tissue thickness does not allow the implant to be safely concealed.<\/li>\n<\/ul>\n<\/article><\/div>\n<figure class=\"aso-plane__figure aso-plane__figure--rippling\">\n      <img src=\"https:\/\/www.doctoraso.es\/wp-content\/uploads\/2015\/11\/rippling.jpg\" alt=\"Visible rippling caused by folds in a breast implant\" width=\"249\" height=\"186\" loading=\"lazy\" decoding=\"async\"><figcaption>An example of rippling. It is not determined by placement alone: coverage, implant, width, volume, skin quality, and dissection all matter.<\/figcaption><\/figure>\n<aside class=\"aso-plane__note aso-plane__note--clinical\">\n<h3>What we are observing with mia and Preserv\u00e9<\/h3>\n<p>In our early experience, ergonomic implants placed subglandularly using mia or Preserv\u00e9, when coverage is sufficient, do not appear to cause more rippling than our historical series of submuscular augmentations. This is our own clinical observation, not yet a comparative study, and should not be interpreted as an individual guarantee.<\/p>\n<\/aside>\n<\/section>\n<section class=\"aso-plane__section\" id=\"subfascial\">\n<h2>Subfascial implants: what does the fascia actually add?<\/h2>\n<p>In subfascial placement, the implant sits beneath the fascia covering the pectoral muscle, but remains above the muscle. The fascia is thin: it does not provide partial muscular coverage and should not be described as a thick additional layer.<\/p>\n<figure class=\"aso-plane__figure aso-plane__figure--diagram\">\n      <img src=\"https:\/\/www.doctoraso.es\/wp-content\/uploads\/2026\/10\/implant-plane-subfascial-en-2026.jpg\" alt=\"Diagram of a subfascial breast implant beneath the fascia and above the pectoral muscle\" width=\"800\" height=\"643\" loading=\"lazy\" decoding=\"async\"><figcaption>Subfascial placement: the implant lies beneath the pectoral fascia but remains above the muscle.<\/figcaption><\/figure>\n<p>Some publications have reported less rippling, hematoma, or capsular contracture than with subglandular placement. However, a 2024 meta-analysis noted that all included studies had a high risk of bias. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/38825810\/\" target=\"_blank\" rel=\"noopener\">Read the meta-analysis by Yuan and colleagues<\/a>.<\/p>\n<p>A later analysis found that, when results were separated by implant surface, capsular contracture rates with contemporary smooth implants were similar for subfascial and subglandular placement. This suggests that part of the historical advantage attributed to placement may have reflected the greater use of textured implants in subfascial series. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/41572725\/\" target=\"_blank\" rel=\"noopener\">Read Abbott and colleagues<\/a>.<\/p>\n<aside class=\"aso-plane__position\">\n<h3>Our clinical approach<\/h3>\n<p>In our opinion and experience, subfascial placement adds very little compared with subglandular placement. We do not claim it has no value, but we do not consider such a thin fascia to meaningfully change implant coverage. We therefore prefer to choose between appropriately indicated subglandular placement and submuscular coverage when the tissues genuinely need it.<\/p>\n<\/aside>\n<\/section>\n<section class=\"aso-plane__section\" id=\"submuscular\">\n<div class=\"aso-plane__label\">Below the muscle<\/div>\n<h2>Submuscular implants: complete and partial coverage<\/h2>\n<p>When we describe an implant as submuscular, we include two possibilities: complete muscular coverage, or only the upper part beneath the pectoral muscle using a dual plane technique. The latter is by far the option we use most often.<\/p>\n<figure class=\"aso-plane__figure aso-plane__figure--diagram\">\n      <img src=\"https:\/\/www.doctoraso.es\/wp-content\/uploads\/2026\/10\/implant-plane-complete-submuscular-en-2026.jpg\" alt=\"Diagram of a breast implant in complete submuscular placement beneath the pectoral muscle\" width=\"800\" height=\"640\" loading=\"lazy\" decoding=\"async\"><figcaption>A diagram of extensive submuscular coverage. In dual plane placement, the muscle mainly covers the upper part, while the gland has a different relationship with the lower pole.<\/figcaption><\/figure>\n<div class=\"aso-plane__pros-cons\">\n<article class=\"aso-plane__pros\">\n<h3>When it can help<\/h3>\n<ul>\n<li>Patients with little fat and glandular tissue in the upper pole.<\/li>\n<li>Greater risk of a visible edge, palpability, or rippling.<\/li>\n<li>Certain breast lifts with implants where better implant stabilization is desirable.<\/li>\n<li>Cases where prepectoral coverage is insufficient for the chosen implant.<\/li>\n<\/ul>\n<\/article>\n<article class=\"aso-plane__cons\">\n<h3>The trade-offs<\/h3>\n<ul>\n<li>More pain and slower recovery than with subglandular placement.<\/li>\n<li>Breast movement or distortion when the pectoral muscle contracts.<\/li>\n<li>An initial tendency for the implant to sit higher.<\/li>\n<li>Possible later separation between a high implant and a gland that descends.<\/li>\n<\/ul>\n<\/article><\/div>\n<aside class=\"aso-plane__note\">\n<h3>Why we almost never use complete submuscular placement<\/h3>\n<p>Complete coverage restricts lower expansion more, is usually more painful, and encourages the implant to remain high. We therefore usually release at least the lower pectoral attachments\u2014dual plane I\u2014to let the implant adapt better to the lower pole.<\/p>\n<\/aside>\n<\/section>\n<section class=\"aso-plane__section\" id=\"dual-plane\">\n<h2>Dual plane: a partial submuscular technique<\/h2>\n<p>Dual plane is not a category separate from submuscular placement. It is a form of partial submuscular placement combining two maneuvers:<\/p>\n<ol class=\"aso-plane__steps\">\n<li><span>1<\/span>\n<div><strong>Release of the lower pectoral attachments.<\/strong> The lower attachments are released so the muscle does not compress the implant or keep it too high.<\/div>\n<\/li>\n<li><span>2<\/span>\n<div><strong>Separation of the gland from the muscle.<\/strong> Depending on the type of dual plane, the space between the breast and the pectoral muscle is extended to different degrees.<\/div>\n<\/li>\n<\/ol>\n<p>The aim is to maintain muscular coverage in the upper area\u2014where the edge may be most noticeable\u2014while allowing the lower breast to adapt better to the implant. Tebbetts&#8217; original description distinguishes different degrees according to the extent of separation between gland and pectoral muscle. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/11373572\/\" target=\"_blank\" rel=\"noopener\">Read the original publication on PubMed<\/a>.<\/p>\n<p>Because it remains a submuscular technique, dual plane involves working on the pectoral muscle: it generally causes more pain and takes longer to recover from than subglandular placement. Compared with complete muscular coverage, releasing the lower attachments facilitates lower-pole expansion and prevents the muscle from holding the implant excessively high.<\/p>\n<figure class=\"aso-plane__figure aso-plane__figure--diagram\">\n      <img src=\"https:\/\/www.doctoraso.es\/wp-content\/uploads\/2026\/10\/implant-plane-dual-plane-en-2026.jpg\" alt=\"Diagram of a dual plane breast implant with upper pectoral coverage and lower pole beneath the gland\" width=\"800\" height=\"643\" loading=\"lazy\" decoding=\"async\"><figcaption>Dual plane: upper muscular coverage and more direct contact between gland and implant in the lower pole.<\/figcaption><\/figure>\n<div class=\"aso-plane__dual-grid\">\n<article>\n<h3><span>Dual plane I<\/span>Release of the lower attachments<\/h3>\n<p>The lower pectoral border is released without extensive glandular separation. This is the minimum submuscular coverage we usually use.<\/p>\n<\/article>\n<article>\n<h3><span>Dual plane II<\/span>Separation up to the lower areola<\/h3>\n<p>Greater separation between gland and muscle helps the tissues adapt to the implant.<\/p>\n<\/article>\n<article>\n<h3><span>Dual plane III<\/span>Higher separation<\/h3>\n<p>May help breasts with greater laxity or borderline sagging, aiming for the gland and implant to change more harmoniously together.<\/p>\n<\/article><\/div>\n<p class=\"aso-plane__data-note\">The exact extent is adapted to the anatomy. These terms describe a surgical strategy; they do not, by themselves, guarantee a particular result.<\/p>\n<\/section>\n<section class=\"aso-plane__section\" id=\"mama-dinamica\">\n<div class=\"aso-plane__dynamic\">\n<div>\n<h2><span>Beyond the photograph<\/span>A natural breast should also look natural in motion<\/h2>\n<p>For many years, surgeons have focused particularly on the static result: front, side, and three-quarter photographs taken while the patient is still. These images are useful, but do not show everything that happens in everyday life.<\/p>\n<p>Women walk, raise their arms, exercise, hug, and contract their pectoral muscles. A submuscular implant may move or distort the contour during contraction. Sometimes the movement is mild; in other cases it produces unnatural animation that does not appear in before-and-after photographs.<\/p>\n<\/p><\/div>\n<aside>\n        <strong>A new clinical priority<\/strong><\/p>\n<p>Today we place greater emphasis on how the breast feels, natural implant movement, and the absence of movement-related distortion, alongside the static result.<\/p>\n<\/aside><\/div>\n<p>A systematic review found that animation deformity is understudied and probably underreported; in the few included studies, its frequency and severity increased with the extent of muscle involvement. <a href=\"https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC6369057\/\" target=\"_blank\" rel=\"noopener\">Read the systematic review<\/a>.<\/p>\n<p>Experienced surgeons are also reconsidering subglandular or prepectoral placement when coverage is adequate. This is a change in approach: not a claim that \u201cabove\u201d is always better, but a move away from using the muscle out of habit when the patient does not need that coverage. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/41640132\/\" target=\"_blank\" rel=\"noopener\">Read the perspective by Montemurro, Gupta, and Mallucci<\/a>.<\/p>\n<\/section>\n<section class=\"aso-plane__section\" id=\"eleccion\">\n<div class=\"aso-plane__label\">A personalized decision<\/div>\n<h2>How we choose placement for each patient<\/h2>\n<p>The choice starts with anatomy, not a favorite technique. We measure coverage, analyze breast and chest shape, assess skin quality, and relate these findings to the implant and the patient&#8217;s priorities.<\/p>\n<div class=\"aso-plane__criteria\">\n<article>\n<h3><span aria-hidden=\"true\">01<\/span>Coverage and pinch test<\/h3>\n<p>In our protocol, we tend to recommend prepectoral placement when the pinch test and coverage are adequate, usually over 2 cm. This is our own criterion, interpreted alongside the rest of the examination.<\/p>\n<\/article>\n<article>\n<h3><span aria-hidden=\"true\">02<\/span>Implant and rippling risk<\/h3>\n<p>Width, volume, cohesivity, gel behavior, and fit to the chest can affect the risk of visible folds as much as placement.<\/p>\n<\/article>\n<article>\n<h3><span aria-hidden=\"true\">03<\/span>Pectoral muscle and activity<\/h3>\n<p>For patients who train their chest extensively or depend on those muscles, movement-related distortion is particularly important.<\/p>\n<\/article>\n<article>\n<h3><span aria-hidden=\"true\">04<\/span>Sagging and skin quality<\/h3>\n<p>We need to anticipate how the gland, skin envelope, and implant will change\u2014not just how they will look during the first few months.<\/p>\n<\/article>\n<article>\n<h3><span aria-hidden=\"true\">05<\/span>Primary augmentation or breast lift<\/h3>\n<p>We increasingly use prepectoral placements for primary augmentation. In many breast lifts, we prefer muscular coverage to help stabilize the implant.<\/p>\n<\/article>\n<article>\n<h3><span aria-hidden=\"true\">06<\/span>Informed preferences<\/h3>\n<p>The patient should understand the balance between coverage, movement, pain, scars, future surgery risk, and expected appearance.<\/p>\n<\/article><\/div>\n<aside class=\"aso-plane__note aso-plane__note--clinical\">\n<h3>Capsular contracture in our mia\/Preserv\u00e9 series<\/h3>\n<p>Among more than 150 consecutive patients treated with mia or Preserv\u00e9, we have not observed any capsular contracture to date. Average follow-up is still around 8 months, and patients with the longest follow-up are approaching 2 years. These are preliminary internal data: they do not establish a zero long-term rate or a causal link to placement, implant, or technique.<\/p>\n<\/aside>\n<\/section>\n<section class=\"aso-plane__section\" id=\"ptosis\">\n<h2>Mild sagging: better visual centering does not mean lifting the nipple<\/h2>\n<p>In a patient with a slightly low nipple or borderline sagging, an implant can develop the lower pole and make the nipple appear better centered relative to breast volume. However, the distance from the sternal notch to the nipple changes little: this is <strong>relative centering, or an optical effect<\/strong>, not a true lift.<\/p>\n<p>If the patient wishes to avoid scars for now and understands that further surgery may be needed, we tend to use prepectoral placement or at least a dual plane III. We aim for the implant to follow the gland more closely if tissues descend, avoiding, where possible, a high implant while the breast falls in front of it.<\/p>\n<div class=\"aso-plane__ptosis-grid\">\n<article>\n<h3>An implant without a breast lift<\/h3>\n<p>May be reasonable for borderline patients who accept future sagging and the possibility of needing a lift later. It does not eliminate sagging or guarantee that a second procedure can be avoided.<\/p>\n<\/article>\n<article>\n<h3>A breast lift with or without an implant<\/h3>\n<p>If the priority is a more stable solution and reducing the likelihood of further surgery in the medium term, we explain that a breast lift addresses skin and nipple position more directly.<\/p>\n<\/article><\/div>\n<aside class=\"aso-plane__note\">\n<h3>What is waterfall or snoopy deformity?<\/h3>\n<p>It occurs when the implant remains relatively high and fixed while the gland and skin descend in front of it. This is one reason we do not assess placement solely by its ability to hold the implant: we must also consider how the implant and breast will age together.<\/p>\n<\/aside>\n<p>3D simulations are particularly useful for these patients. They let us compare what an implant alone can achieve, how much visual centering is realistic, and what would change with a breast lift.<\/p>\n<\/section>\n<section class=\"aso-plane__section\" id=\"evidencia\">\n<div class=\"aso-plane__label\">A critical reading<\/div>\n<h2>What do we know about contracture, rippling, and other complications?<\/h2>\n<p>Studies do not identify one placement that wins on every outcome. A 2026 meta-analysis found higher pooled capsular contracture rates with subglandular than submuscular placement, whereas other problems\u2014such as animation deformity, a high position, or certain malpositions\u2014are more closely associated with muscular coverage. The authors stress individualized selection and note differences between studies. <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/41748776\/\" target=\"_blank\" rel=\"noopener\">Read the 2026 meta-analysis<\/a>.<\/p>\n<div class=\"aso-plane__evidence-grid\">\n<article>\n<h3><span>Placement and contracture<\/span>Pooled figures do not predict an individual patient&#8217;s outcome<\/h3>\n<p>Surface, implant generation, technique, contamination, follow-up, and anatomical selection can affect observed rates.<\/p>\n<\/article>\n<article>\n<h3><span>Placement and rippling<\/span>Coverage matters, but does not act alone<\/h3>\n<p>Muscle can better conceal the upper pole, while gel, size, width, tissues, and dissection influence the rest of the breast.<\/p>\n<\/article>\n<article>\n<h3><span>Placement and movement<\/span>Pectoral contraction changes the result<\/h3>\n<p>Prepectoral implants avoid muscular animation; submuscular implants provide coverage at the cost of altered movement.<\/p>\n<\/article>\n<article>\n<h3><span>Placement and recovery<\/span>Working on the muscle has a cost<\/h3>\n<p>In our experience and comparative studies, submuscular placement causes more pain and slower recovery than subglandular placement.<\/p>\n<\/article><\/div>\n<aside class=\"aso-plane__publication\">\n<div>\n<h3><span>A publication from the clinic<\/span>Marcelli\u2013Aso: 621 aesthetic breast procedures<\/h3>\n<p>The retrospective series compared POLYtxt and MESMO implants, with an average follow-up of 30 months. Capsular contracture was comparable between the groups; the public abstract does not provide the exact percentage, and we do not use this study to compare placements. It did show more late seroma, overall complications, and reoperations with POLYtxt.<\/p>\n<\/p><\/div>\n<p>      <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/33582050\/\" target=\"_blank\" rel=\"noopener\">Read the publication on PubMed<\/a><br \/>\n    <\/aside>\n<\/section>\n<section class=\"aso-plane__section\" id=\"galeria\">\n<h2>Photographs help, but need movement and context<\/h2>\n<p>A static image does not show pectoral contraction, feel, mobility, or how the breast behaves when the arms are raised. Nevertheless, comparing cases with similar anatomy, volume, and technique helps explain what each placement can offer.<\/p>\n<aside class=\"aso-plane__gallery\">\n<div>\n<h3><span>Comparable real cases<\/span>Explore results by volume, height, weight, shape, and technique<\/h3>\n<p>The interactive gallery lets you find patients with similar characteristics and assess results with round, anatomical, and ergonomic implants.<\/p>\n<\/p><\/div>\n<p>      <a href=\"https:\/\/www.doctoraso.es\/en\/breast-augmentation-before-and-after\/\">View the breast augmentation gallery<\/a><br \/>\n    <\/aside>\n<\/section>\n<section class=\"aso-plane__section\" id=\"preguntas\">\n<h2>Frequently asked questions about implants and the pectoral muscle<\/h2>\n<div class=\"aso-plane__faq\">\n<details>\n<summary>What does a submuscular implant mean?<\/summary>\n<p>It means the pectoral muscle covers all or part of the implant. In our explanation, the term includes both complete submuscular placement and dual plane, or partial submuscular coverage.<\/p>\n<\/details>\n<details>\n<summary>Is dual plane the same as below the muscle?<\/summary>\n<p>It is a partial submuscular approach. The pectoral muscle mainly covers the upper part, while release of its lower attachments and separation between gland and muscle allow a different relationship with the lower pole.<\/p>\n<\/details>\n<details>\n<summary>Which placement is recommended if I have very small breasts?<\/summary>\n<p>It depends on actual coverage thickness, not just breast size. When tissue is thin or the pinch test is insufficient, we usually prefer submuscular coverage to reduce palpability and rippling. Examination and simulation help determine the implant and placement.<\/p>\n<\/details>\n<details>\n<summary>Do implants below the muscle look more natural?<\/summary>\n<p>Not necessarily. They may better conceal the upper edge in thin patients, but can also distort when the pectoral muscle contracts. With adequate coverage, prepectoral placement can provide very natural movement and feel.<\/p>\n<\/details>\n<details>\n<summary>Do implants above the muscle cause more rippling?<\/summary>\n<p>The risk may increase when coverage is limited, but placement is not the only factor. Implant, width and volume, gel behavior, skin, and precise dissection all matter. With adequate coverage, visible rippling does not necessarily increase.<\/p>\n<\/details>\n<details>\n<summary>Are submuscular implants more painful?<\/summary>\n<p>Yes. Working on and releasing the pectoral muscle generally causes more pain and slower recovery than subglandular placement. Severity varies with technique, patient, and pain-control protocol.<\/p>\n<\/details>\n<details>\n<summary>Can I train my pectoral muscles with submuscular implants?<\/summary>\n<p>Many patients can do so after recovery, but contraction may move or visibly distort the implant. For athletes with highly developed pectoral muscles, we give this effect particular attention before choosing placement.<\/p>\n<\/details>\n<details>\n<summary>Can dual plane lift a sagging breast?<\/summary>\n<p>It does not perform a breast lift. It can develop the lower pole and visually center the nipple in a borderline patient, but does not meaningfully raise its anatomical position. With true sagging, a breast lift is the more direct and stable solution.<\/p>\n<\/details>\n<details>\n<summary>Does subfascial placement provide more coverage than subglandular placement?<\/summary>\n<p>It adds the fascia, a very thin layer, but not muscular coverage. Some series have reported advantages; in our practical experience, the difference from subglandular placement is small, and some historical results may have been influenced by implant surface.<\/p>\n<\/details><\/div>\n<\/section>\n<footer class=\"aso-plane__conclusion\">\n<h2>The key point: adequate coverage without overlooking movement<\/h2>\n<p>When breast coverage is adequate, prepectoral placement can offer very natural feel, movement, and recovery without muscular distortion. When tissues are thin or the risk of rippling is greater, submuscular coverage\u2014usually dual plane\u2014may be the more balanced option.<\/p>\n<p>The choice cannot be reduced to a photograph of the result or a surgeon&#8217;s technical preference. It should consider anatomy, implant, activity, tissue aging, possible sagging, and each patient&#8217;s priorities. At <a href=\"https:\/\/www.doctoraso.es\/en\/\">Dr. Jorge Aso Clinic<\/a> we use examination, the pinch test, comparable cases, and 3D simulation to explain clearly what each alternative can achieve.<\/p>\n<p>    <a class=\"aso-plane__cta\" href=\"https:\/\/www.doctoraso.es\/en\/contact\/\">Request a personalized assessment<\/a><br \/>\n  <\/footer>\n<aside class=\"aso-plane__history-note\">\n    <strong>A note on historical comments<\/strong><\/p>\n<p>The original article retains questions and answers published since 2016. They help illustrate real cases, but some reflect the criteria, implants, and evidence available at the time. For general guidance, the reviewed and dated article content should take precedence; any individual recommendation requires a current assessment.<\/p>\n<\/aside>\n<p>  <br \/>\n<\/article>\n<p>[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][vc_column_text] Implant placement and results in motion No single placement is best for every patient. When there is enough tissue coverage, placing the implant above the muscle allows the breast to move more freely, avoids distortion when the pectoral muscle contracts, and often makes recovery easier. When tissues are thin or the risk of rippling [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_joinchat":[],"footnotes":""},"categories":[78,80],"tags":[],"class_list":["post-23949","post","type-post","status-publish","format-standard","hentry","category-breast-augmentation","category-cosmetic-surgery"],"acf":[],"featured_image_src":{"landsacpe":false,"list":false,"medium":false,"full":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.7 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Breast Implants Above or Below the Muscle | Dr. Aso<\/title>\n<meta name=\"description\" content=\"Compare subglandular, subfascial, submuscular, and dual plane breast implants: tissue coverage, movement, rippling, recovery, and individualized selection.\" \/>\n<meta name=\"robots\" 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