Behind the Muscle or Over the Muscle The next consideration is where to place the breast implant – on top of or behind the muscle. In general, I prefer to place breast implants behind the muscle so that they are partially covered. I find the pectoralis muscle allows a smooth takeoff from the chest wall. If put directly on top of the muscle, the breasts can look like rounded balls on the chest which is a definite give-away. It is also my opinion that placing the implant under the muscle will, in the long run, have an impact on breast droopiness. Also for older women that need breast cancer screening, it seems that behind the muscle placement is superior from a mammogram and ultrasound imaging point of view. A further advantage of the submuscular pocket is a lower rate of capsular contracture. But it is not all perfect with the submuscular placement of implants. The negatives of the submuscular pocket is that it may create “winking” on animation or flexing of the pectoralis muscle. Implant migration and displacement is also more likely in this pocket. Dual-Plane Technique In women with mild droopy (ptotic) breasts, I use the dual-pocket technique of dissecting both on top of and underneath the pectoral muscle (50% over and 50% under the muscle), but inserting the breast implant behind the muscle. This new technique popularized by Texan Plastic Surgeon Dr John Tebbett and Swedish Plastic Surgeon Dr Per Heden is proving very successful with most types of breast augmentation that I see in my practice. In rare cases of moderate droopy breasts where the patient does not wish to undergo a breast lift procedure for fear of scaring, I will consider placement of the implant on top of the muscle. This pocket is referred to in the plastic surgery literature as subglandular or subfascial . Generally speaking, it is a relatively painless pocket with excellent short-term benefits but in my opinion far less long-term advantages compared to the submuscular or subpectoral pocket placement. Having said this please note that most types of constricted or Tuberous breast corrections are done with implants in the Subglandular or Subfascial pocket as the risks of Double-Bubble is considerably higher in Tuberous breasts.