Rethinking Implant Plane Selection: Do We Still Need to Go Under the Muscle?

BACKGROUND: Dual-plane breast augmentation has traditionally been the standard approach in aesthetic breast surgery, while prepectoral placement was reserved for selected anatomical indications. Advances in implant technology and growing clinical experience have led to a renewed reassessment of these beliefs. OBJECTIVES: To describe a shift in clinical practice from predominantly dual-plane to more frequent prepectoral breast augmentation, supported by years of retrospective data and qualitative clinical insight. METHODS: We reviewed all primary breast augmentations performed over a four-year period (2021-2024) and compared these data with cases performed by the same author between 2009 and 2020. The analysis focused on the rationale for plane selection, patient characteristics, and implant volume. The discussion integrates reflections from an experienced plastic surgeon with more than 2,000 augmentations. RESULTS: Subglandular placement increased substantially over time. It accounted for only 3.25% of augmentations performed between 2009 and 2020, rising to 21.7% in 2021-2022 and reaching 42.2% in 2023-2024. This progressive shift reflects growing clinical confidence in the technique and increasing patient preference. CONCLUSIONS: Implant plane selection should be individualised. The increased use of prepectoral augmentation reflects a shift in surgical strategy driven by anatomy, patient activity level, and aesthetic objectives. When appropriately indicated, avoiding muscle manipulation can yield favourable and reliable outcomes.