How to Choose the Right Breast Implant Pocket for You

Breast Augmentation is one of the most popular cosmetic surgery procedures performed yearly by Plastic Surgeons. And while the trends of breast augmentation have changed over the years, it still remains one of the more popular procedures in my Seattle Plastic Surgery practice. Just like any cosmetic surgery procedure, the decision to undergo a breast augmentation can feel like a big one— how do you even choose a size? A profile? And, in this day and age, an implant company? While it is in fact a big commitment, it’s really a series of smaller, more thoughtful choices that shape your final results.

One of the key decisions we’ll make together during your consultation is where to place the breast implant: above or below your pectoralis major muscle.

The conversation and trends around implant pocket placement has evolved significantly over the last few decades. What was once a one-size-fits-all approach has grown into a nuanced discussion fueled by advancing implant technology, changing aesthetic ideals, and, most importantly, individual patient goals and anatomy.

So, let’s break it down: What does it mean to go under the muscle? What are the benefits of staying over the muscle? And how do we decide what’s right for you?

A Quick Anatomy Lesson: Over vs. Under the Muscle

To start, let’s define our terms. The “muscle” in question here is your pectoralis major—that large, fan-shaped chest muscle that sits just beneath your breast tissue.

When we talk about subglandular or subfascial implant placement, we’re placing the implant above the muscle, nestled just behind the breast tissue.

When we talk about submuscular implant placement, the implant goes under the pectoralis major muscle—at least partially. In most submuscular augmentation techniques, the lower border of the muscles is released, allowing a more natural position of the breast implant on the chest wall (and avoiding a high-riding implant placement). This means that the lower portion of the implant falls below where the muscle is released, leaving the implant covered only by breast tissue. 

Over the muscle, Hybrid (Dual Plane Pocket), and Total Submuscular Placement

How the Implant Pocket Trend Have Shifted

Traditionally, breast implants were placed above the muscle. And for many patients, that worked well—especially in cases with ample natural breast tissue. However, over time, concerns emerged around implant visibility and palpability, particularly in leaner patients. Enter submuscular placement, which offered patients an extra layer of soft tissue coverage and, for some, a more natural upper pole transition.

Like most things in plastic surgery, trends ebb and flow. For years, the pendulum swung hard toward submuscular placement—so much so that it became the default. And this makes sense– most patients seeking a breast augmentation likely have very little of their own breast tissue; therefore, most patients seeking a breast augmentation would benefit from extra soft tissue coverage and thus submuscular placement. And in my practice, submuscular placement of breast implants is still the overwhelming choice for many patients. But recently, I’ve noticed a resurgence in patients (and surgeons) reconsidering above-the-muscle options. Why? Less muscle disruption, no risk of animation deformity, and better compatibility with newer implant technologies.

But this isn’t a blog post about trends. It’s about choosing what’s right—for you.

The 4 Decisions in Every Breast Augmentation Consultation

In my Seattle plastic surgery practice, when I meet with a patient for a breast augmentation consultation, we walk through four main decisions together:

1. Incision location

2. Pocket placement (over or under the muscle)

3. Implant type (saline vs. silicone)

4. Implant size and profile

   
   

Each of these choices is personalized. There is no universal “right answer.” My role as your surgeon is to listen carefully to your goals, examine your unique anatomy, and offer recommendations based on experience, safety, and your long-term satisfaction.

When it comes to helping us answer these questions, I look at a number of key anatomical features to guide me: 

• Amount and quality of natural breast tissue

• Degree of upper pole fullness

• Skin laxity or tightness

• Position of the nipple on the chest wall

• Presence of pseudo-ptosis (bottoming out of the breast)

• Pectoralis muscle definition and thickness

• Your athletic lifestyle or profession

  
  

I also want to understand your preferences: Do you want a very natural look or a high-profile, rounder shape? Are you leaning toward silicone or saline? Do you have photos of “wish pics” to look at? Let’s take a closer look at the pros and cons of each pocket placement option.

Under the Muscle (Submuscular): Pros and Cons

 Pros of Going Under the Muscle:

1. More Natural Upper Pole Slope When the pectoralis muscle drapes over the top portion of the implant, it creates a gentle, sloped transition—especially in patients with minimal breast tissue. This often gives a more natural look in the upper chest, which tends to be the thinnest part of the chest.

2. Better Soft Tissue Coverage Particularly in leaner patients, submuscular placement offers more coverage over the implant, helping to disguise edges, reduce rippling, and lower the risk of visible implant outlines.

3. May Reduce Capsular Contracture RiskEvidence consistently shows that submuscular placement of a silicone breast implant  reduces the risk of capsular contracture (a hardening of scar tissue around the implant).

4. Improved Long-Term Support The muscle may offer some additional support to help keep the implant in position over time, although this is still debated among surgeons.

   
   

Cons of Going Under the Muscle:

1. Muscle Manipulation In order to place the implant under the pectoralis muscle, I need to release the lower portion of the muscle from its insertion on the ribcage. While this does not destabilize the muscle or affect strength significantly, it does create a new “normal” for your body.Most patients get used to this within 6–8 weeks. But initially, it may feel like tightness, pressure, or unusual chest movement during activity.

2. Animation Deformity This occurs when the muscle contracts—such as during exercise or lifting—and causes visible movement or distortion of the implant. It’s more common in patients with strong, thick chest muscles or those who weight train regularly.

3. Slightly Longer Recovery Because the dissection involves muscle release, submuscular placement may require a bit more downtime and discomfort in the early post-op period.

Over the Muscle (Subglandular): Pros and Cons

Pros of Going Over the Muscle:

1. No Muscle Disruption This is the biggest advantage: we’re not manipulating your pectoral muscle at all. That often means less pain, easier recovery, and no animation deformity—a major consideration for athletes or patients in fitness industries.

2. Shorter Surgical Time and Recovery Because we’re not dissecting the muscle, the surgery is slightly faster and the healing process can feel more straightforward.

3. Better Implant Control in Certain Anatomies In patients with mild sagging or skin laxity, over-the-muscle placement can give better shape control, especially if combined with newer generation cohesive silicone implants or a concurrent lift.

4. Avoids Distortion with Muscle Movement If you’re someone who teaches yoga, lifts weights, or works a physical job, you may prefer the predictability of an implant that doesn’t shift when your muscle activates.

   
   

Cons of Going Over the Muscle:

1. Less Tissue Coverage For patients with very little breast tissue, over-the-muscle placement may result in more visible implant edges or rippling—especially with saline implants or thinner skin.

2. Potentially Less Natural Upper Pole Without the muscle draping over the top of the implant, the transition from chest wall to implant can sometimes appear more abrupt or “implant-y,” particularly in very slim patients.

3. Slightly Higher Capsular Contracture Rates Some data suggest that subglandular placement of a silicone breast implant carries a slightly higher risk of capsular contracture over time, although modern implant materials and surgical technique have helped mitigate this.

So, Which One is Right for You?

There’s no “better” or “worse” here—just different pros and cons based on your body, your lifestyle, and your goals.

As a board-certified female plastic surgeon in Seattle, my job is to walk you through these trade-offs and make a plan that fits you. What feels empowering to one patient may feel limiting to another, and that’s okay.

Here’s a quick guide to help clarify where you might fall:

Under the Muscle Might Be Right If:

• You’re very lean with minimal breast tissue

• You’re concerned about implant visibility

• You prefer a natural slope and upper pole appearance

• You don’t mind a slightly longer recovery

• You don’t do heavy chest-focused weightlifting

Over the Muscle Might Be Right If:

• You have a moderate amount of natural breast tissue

• You prioritize an easier recovery and less pain

• You’re very active, especially in fitness or bodybuilding

• You’re trying to avoid animation deformity

• You want more control over the implant shape without muscle interference

The Role of Implant Technology

One more piece of the puzzle: modern breast implant technology has come a long way. Today’s silicone implants are highly cohesive, meaning they hold their shape better and ripple less—making over-the-muscle placement a more viable option for more people than it was 10 or 15 years ago.

We now have access to a wider range of implant profiles, gel firmness levels, and shapes. These tools help us fine-tune your outcome—whether we’re working under the muscle or over it.

Final Thoughts: Personalized Plastic Surgery Is the Goal

Every breast augmentation I perform is customized. There’s no copy-paste formula. During your consultation at my Seattle plastic surgery office, we’ll evaluate your anatomy together, talk through your aesthetic goals, and build a surgical plan that checks your boxes.

Whether we go over or under the muscle isn’t just a technical choice—it’s part of your story. It’s about how you want your body to feel, look, and function for years to come.

As a female plastic surgeon, I approach each case with empathy, precision, and a deep understanding of how cosmetic choices intersect with identity, confidence, and lifestyle.

If you're considering breast augmentation and want expert, personalized care, I invite you to schedule a consultation. Together, we’ll create a result that feels like you—only elevated.

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Dr. Megan Dreveskracht is a board certified Plastic Surgeon in Seattle, Washington. To learn more about your plastic surgery procedure, Schedule your consultation today

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