For most silicone breast augmentation patients, the answer is dual plane through an incision in the breast fold. The top of the implant sits behind the chest muscle, the bottom behind the breast tissue, placed through the under-breast crease. Here is why that combination became the default, and when the other options make sense.
Where can the implant actually sit?
There are four placement options, and each has a clear personality.
Under the muscle (submuscular). The implant goes behind the pectoralis major muscle. This is the most widely used placement. It gives a natural slope to the upper breast, hides rippling better, has lower rates of capsular contracture, and makes mammograms easier to read. The downsides: recovery is longer and more painful, and you can get animation deformity, the visible shift of the implant when the chest muscle flexes. It also takes weeks to months for everything to settle.
Over the muscle (subglandular). The implant sits under the breast tissue but on top of the muscle. Recovery is faster and less painful, the upper breast looks fuller with more cleavage, there is no animation deformity, and it can give a subtle lifting effect for mild sag. The trade-offs are more visible rippling in thin patients, higher contracture risk, and more interference with mammograms. Here is the key point: silicone ripples less than saline, and that is specifically what makes over-the-muscle placement a realistic option for silicone implants.
Dual plane (the hybrid). The top of the implant goes behind the muscle and the bottom goes behind the breast tissue. You get most of under-the-muscle's natural coverage with some of over-the-muscle's lower fullness, plus a slight lift for mild drooping. It is the modern default, though not a substitute for a real breast lift when sagging is significant.
Subfascial. The implant goes under the thin fascia layer that covers the muscle, with the muscle left intact. The result looks natural, there is no animation deformity, and recovery is quick. It is technically demanding and not every surgeon offers it.
How does your surgeon actually decide?
It starts with your tissue. Surgeons use the pinch test: they pinch the skin at the top of the breast to measure how much soft tissue covers the implant's upper edge. If that tissue layer is thin, over-the-muscle placement is generally ruled out for a natural result. There just is not enough coverage to hide the implant's edges, and rippling becomes likely. That one measurement pushes the decision toward under-the-muscle or dual plane.
Your frame matters too. On a very thin patient with little breast tissue, under-the-muscle or dual plane hides the implant better. On a patient with generous tissue, over-the-muscle can look completely natural and avoids the longer recovery.
Then there is lifestyle. If you train chest muscles hard, animation deformity becomes a daily annoyance, and over-the-muscle or subfascial starts looking attractive. And if there is mild drooping, dual plane's subtle lift can solve it; real sagging still needs a lift.
Why does silicone change the placement math?
Two reasons, both practical.
First, silicone gel mimics natural breast tissue and ripples far less than saline. Over-the-muscle placement's biggest weakness is visible rippling in thin patients. Silicone shrinks that weakness, which is why subglandular placement is mostly a silicone conversation.
Second, silicone implants arrive pre-filled. They need an incision of about 4 to 5 cm, versus the smaller opening saline allows (saline goes in empty and is filled after placement). That incision length quietly rules some incision options in or out, which is the bridge to the next decision.
Where will the scar be?
The incision and the placement are one plan, because the incision must be big enough for the implant and positioned to give the surgeon real control.
Under the breast fold (inframammary). The most common choice, and the precision standard. It works with all implant types and sizes, gives the surgeon the best control of the pocket and symmetry, and can be reused for future revisions. It does not affect nipple sensation or breastfeeding, and the scar hides in the natural crease. For silicone patients, this is usually the straightforward pick.
Around the areola (periareolar). The scar blends into the color border, so it is discreet. But it comes with trade-offs: higher risk of nipple sensation changes, more interference with breastfeeding, and higher contracture risk. There is also a geometry problem with silicone. A silicone implant needs a 4 to 5 cm incision, and a small areola simply cannot accommodate it. For future nursing, the submuscular-plus-inframammary combination is the safest bet [1].
Through the armpit (transaxillary). No scar on the breast itself, and it can be done endoscopically. The price is precision: higher risk of implant malposition, the incision cannot be reused for revision surgery, and it is generally not recommended for large or cohesive silicone implants. The distance from armpit to pocket makes the 4 to 5 cm silicone incision requirement awkward.
Through the belly button (transumbilical/TUBA). Saline only, and the least precise option. It does not belong in a silicone conversation.
Scars flatten and fade significantly over roughly 12 months, and silicone gel sheeting plus sun protection help.
So what is the usual answer?
Dual plane through the breast fold. It handles the most body types, gives the most natural result for the widest range of patients, and leaves the easiest path if you ever need a revision. Over-the-muscle earns its place for the right anatomy (enough tissue, preference for easier recovery), and periareolar earns its place when scar placement matters most and the anatomy supports it.
Frequently asked questions
What exactly is dual plane placement?
The top of the implant sits behind the chest muscle while the bottom sits behind the breast tissue. You get the natural upper coverage of under-the-muscle with some of over-the-muscle's lower fullness, plus a slight lift for mild drooping. It is the modern default for silicone augmentation.
How does my surgeon decide between over and under the muscle?
It starts with the pinch test: the surgeon pinches the skin at the top of the breast, and if the tissue at the top of the breast is thin, over-the-muscle placement is generally ruled out. Frame, lifestyle, and any drooping complete the decision.
Where will my scar be?
Most likely the breast fold. The inframammary incision is the most common choice and the precision standard: it works with all implant types, gives the best pocket control, and can be reused for revisions. Scars flatten and fade significantly over roughly 12 months.
Can I breastfeed after getting implants?
The incision-plus-placement combination matters here. For future nursing, the submuscular-plus-inframammary combination is the safest bet, since it avoids the milk ducts and nerves involved in other approaches [1].
Why can't I get silicone implants through the armpit or belly button?
Geometry. A silicone implant needs a 4 to 5 cm incision because it arrives pre-filled, which makes the long transaxillary tunnel awkward; that route is generally not recommended for large or cohesive silicone implants. The transumbilical (belly button) route is saline only and the least precise option.
Sources
[1] https://health.clevelandclinic.org/can-you-breastfeed-with-breast-implants/This conversation is worth having in person, with measurements. At a consultation at Nip Tuck Aesthetics, Dr. Michael Stefan will do the pinch test, measure your breast footprint, and walk through which combination of placement and incision suits your body. Nip Tuck Aesthetics, 8501 SW 124 Ave Suite #317, Miami, FL 33183. Book a consultation and bring your questions about scars, animation, and recovery.
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