My Thoughts on Over-the-Muscle Breast Augmentation (and How They've Changed)

This is one of the rare areas where my own practice has meaningfully evolved over the last 10 years. I want to walk you through it honestly — what we used to do, why we did it, why I've changed, and where I've landed for both cosmetic and reconstructive patients.

For decades, the dominant approach in breast augmentation was over the muscle (subglandular).

Then the data shifted.

• The best research available at the time showed higher rates of capsular contracture and other complications when implants were placed over the muscle
• Plastic surgeons collectively migrated to under the muscle (and especially dual plane) augmentation
• That data drove training, drove board review, and drove practice patterns

For my first roughly 10 years out of training, I did pretty much all dual plane augmentations. I wasn't doing it out of habit — I was doing it because the data told me that's how to minimize complications for my patients. That's what good evidence-based practice is supposed to look like.

But here's what I observed over those 10 years:

Patients really don't like under-the-muscle augmentations.

The biggest issue is animation deformity — the muscle movement that happens when you flex your chest, even when the muscle is technically released only the "right amount" with no over-release or double bubble.

In the plastics community, we sometimes underplay how much animation deformity bothers patients. The reality:

• It's not normal to see your chest move like that every time you move your arms
• It looks odd, even when it's technically "mild"
• Patients notice it constantly — in mirrors, in workout videos, in photos
• The more body-aware the patient (yoga, Pilates, weight training, dance), the more it bothers them
• Even patients who can intellectually understand it don't love seeing it

Add in patients who don't like the feeling of an implant tucked under their pec — especially when they exercise — and you have a real, persistent dissatisfaction signal.

Two things shifted at the same time, which together opened the door for many of us to move back to over-the-muscle augmentation:

The last 5–6 years have seen a real, patient-driven push back to over-the-muscle augmentation in both:

• Cosmetic breast augmentation
• Breast reconstruction (direct-to-implant and prepectoral)

The driver isn't a new study or a new technique. It's patients telling us they want a different trade-off.

The historical higher complication rate of over-the-muscle augmentations was real — but we've learned a lot about what was driving it.

In 2025-era practice, we now know that complication rates can be brought down significantly with:

• Smart incision placement (inframammary over periareolar)
• Effective irrigation solutions (hypochlorous acid, betadine)
• Keller Funnels for no-touch implant insertion
• Nipple shields / Tegaderms to contain ductal bacteria
• Glove changes before handling the implant
• Re-prepping the skin before placement
• Modern, more cohesive, more durable implants

When you stack all of these together, you can safely place implants over the muscle and keep complication rates similar to under-the-muscle placements. That's a genuine shift from where we were 15 years ago — and it's why so many of us in plastic surgery have transitioned back.

For both my cosmetic augmentation patients and my breast cancer reconstruction patients, I've transitioned predominantly to over-the-muscle (or subfascial) placement.

A few honest disclosures:

I have breast implants myself. I've had them placed under the muscle and over the muscle at different points. Personally, I like them so much better over the muscle. That's an n of 1, but the difference is real.

Across my practice, patients consistently report higher satisfaction with over-the-muscle results — even when there are some compromises (which I'll get to next).

It's not a free win. There are real downsides to over-the-muscle placement that need to be discussed with patients.

Without the muscle covering the top of the implant, you may see the implant edge more — especially if you're thin with minimal native tissue.

I've written separately about strategies for hiding implant edges in thin patients (fat grafting, careful implant selection, etc.).

All implants ripple — 100% of them. Whether you actually see it depends on:

• The shape of your chest wall
• How thin or thick your tissue is
• How tight or loose your capsule is
• How cohesive the implant is

Without muscle on top, more of those folds can transmit through to the surface, especially in thin patients.

Worth flagging: the Motiva implants that have come into the U.S. market have dramatically reduced rippling visibility in my patients. Knock on wood, I genuinely don't see rippling like I used to in thin over-the-muscle patients. The implant technology has gotten that much better.

Here's what I've found from talking to my patients about it:

That's the trade. And for most patients, it's the trade they'd choose if both options were laid out clearly.

To be clear: I haven't completely abandoned dual plane. There are still patients for whom under-the-muscle (or dual plane) makes the most sense:

• Very thin patients with minimal tissue and high concern about implant visibility
• Patients who specifically don't mind animation deformity and want maximum tissue coverage
• Patients with specific anatomic features that favor it

But these are now a minority of my augmentation patients, where they used to be essentially everyone.

When you go in for your consultation, ask your surgeon directly where they tend to place implants and why.

Reasonable answers might include:

• "I've transitioned to over the muscle because patient satisfaction is meaningfully higher."
• "I primarily do dual plane in patients with minimal soft tissue."
• "I tailor placement to the individual patient based on tissue, anatomy, and goals."

Less reasonable answers:

• "I always do under the muscle because that's what we do."
• "Over the muscle is dangerous." (We covered why this kind of absolutist fear-mongering is misleading.)

In 2025, with modern implants, modern OR techniques, and 15 years of accumulated learnings, over-the-muscle breast augmentation is safer and more predictable than it used to be — and patients consistently prefer it because it eliminates animation deformity.

I've transitioned the majority of my cosmetic and reconstruction patients to over-the-muscle placement. The trade-offs (slightly more visible edge, slightly more rippling potential) are real, but most patients would rather accept those than deal with chest movement and the under-muscle "implant feel."

If you're early in your augmentation research, this is a worth having on your radar — and worth asking your surgeon about directly.