Ask a doctor

How Do Saline Breast Implants Look if Placed over the Muscle?

Doctor Answers 26

November 3rd, 2009

Saline Implants on Top of the Muscle are NOT for Most Patients

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
I like saline implants above the muscle when the patient...
  • ...already has a fair amount of breast tissue.
    • Saline implants tend to ripple more than silicone.
    • Hence, those implants need some sort of coverage to camouflage that rippling.
    • That coverage can come from the muscle or from breast tissue.
    • If a woman's breasts are already big, but she would like them even bigger, placing implants on top of the muscle is usually OK.
  • ...wants the most natural results when she exercises (nearly) naked(!)
    • The breasts are naturally on top of the muscles.
    • Therefore, if the muscles move, the overlying breasts shouldn't move that much.
    • However, if the implants are beneath the muscles, the breasts might move unnaturally when the muscles contract.
    • Since most women don't exercise naked, this is a minor issue for most patients.
    • Nevertheless, some women do compete in sports in small bikinis, and they are aware of breast distortions with shoulder/chest muscle contractions (such as beach volleyball players, surfers, body builders...see below)
  • ...is a body builder.
    • Body builders have very well developed muscles.
    • Contraction of those big muscles would significantly distort the positions of sub-muscular implants.
    • These women do pose nearly naked (in small bikinis) while flexing their muscles.
    • Even though these women do not have a lot of body fat, implants on top of the muscle are generally better.
    • In competitions, the rippling of the implants looks less bad than implant distortion.
  • ...has droopy breasts and prefers to avoid formal lift-up procedures
    • Implants themselves provide breast rejuvenation.
    • The muscles tend to mute the rejuvenative/lift-up effects of breast augmentations.
    • Even though many women need mastopexies (lift-up surgeries) at the same time as their augmentations, some patients prefer to avoid the additional scars of mastopexies and accept the limitations of implants on top of the muscles.
  • ...is looking for a quicker recovery
    • Most breast implants surgeries do not require a long recovery.
    • However, positioning of the implants below the muscle is more uncomfortable.
    • Staying on top of the muscle is much less painful.
Generally, I use silicone implants when patients choose to have their augmentations on top of the muscle. Or, better yet, I place implants beneath the muscle in 90% of circumstances...
  • to minimize rippling
  • to reduce excess scar tissue around the implants (known as capsular contracture)


Ventura Plastic Surgeon

November 2nd, 2009

Saline Implants above the muscle

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
For most patients seeking breast augmentation, a saline implant looks better if it is under the pectoralis muscle. Most of the augmentation patients don't the enough soft tissue coverage to camouflage the rippling effects of the saline implant on the upper breast pole noted when the patient is in the upright standing position.
It takes at least 2.5 to 3.0cm of soft tissue coverage to be able to use a saline implant in the sub glandular position and then over time as hormonal, metabolic and signs of aging occur, the soft tissue coverage can thin out and the breast may look like a water bag, not pretty. Gel implants work better over the muscle as opposed to saline.

Paul Rottler, MD
Saint Louis Plastic Surgeon

October 29th, 2009

Saline or any breast implants "above the muscle"

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Saline implants placed above the pectoralis major muscle will look ripply, noticeable, obvious, and unnatural. With thick enough skin or enough breast tissue this may not be the result at first, but the experience has been that skin doesn't stay thick and breast tissue doesn't always stick around over time. Usually short term but nearly always long term, saline breast implants will look obvious.

Gel-filled breast implants can initially look natural above the muscle if they are sized and placed properly but will still very likely become noticeable as time goes by and the skin and tissues age. For a natural look, you don't want to see the border or bulge of an implant in the upper and medial parts of the breast. It's normal to have a bulge and an edge to the lower and lateral parts of the breast where the muscle doesn't cover anyway.

Experience has shown rather conclusively that all breast implants should be placed behind the pectoralis major muscle to provide padding, protection, and partial separation of the implant from the breast tissue. This provides a better result both short term and long term.

The other advantages to sub-pectoral (below the muscle) placement of breast implants are possible reduction in capsule contracture rate and ease of obtaining mammograms with implants in place. The disadvantage or trade-off of below the muscle positioning is muscle pull across the lower part of the breast on actively flexing the pectoralis muscle. This can be minimized by release of the lower-lateral border of the muscle during the placement of the implant (dual-plane release).

Scott L. Replogle, MD
Boulder Plastic Surgeon

October 29th, 2009

Saline implants above the muscle

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
The good thing about saline implants above the muscle is that they move like normal breasts and have a quick recovery. The bad thing is that they often exhibit more wrinkling and rippling in the upper part of the breast. There is also a higher incidence of excessive scar tissue, or capsular contracture. I do this approach for patients who may be a bit droopy and don't want a lift, are professional bodybuilders, or are looking for a quicker recovery.

Anthony Youn, MD, FACS
Detroit Plastic Surgeon

October 28th, 2009

Saline implants above muscle may not look natural

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
It all depends on how much breast tissue you have. If too thin, saline breast implants can take on a "grapefruit" appearance when placed over the muscle. Under the muscle is usually better with less complications.
Barry E. DiBernardo, MD
November 10th, 2009

Saline Implants over the muscle

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
I typically do not recommend implants to be placed directly under the breast tissue unless a previously placed submuscular implant is causing problems (scar contracture, etc.). Their are surgeons who will place implants under the gland to compensate for dropping/ sagging tissue...I think this results in an elongated (rock-in-sock) appearance that I personally do not care for...But I have heard patients say, when you see 10 different plastic surgeons, you may get 10 different opinions on what needs to be done.
So, see as many surgeons (Board Certified Plastic Surgeons) as you feel comfortable with, review their results, above and below the muscle, and evaluate what results most exemplify your goals and go with that surgeon!
I hope this abbreviated response helps!
Dr. C

John Philip Connors III, MD, FACS
Atlanta Plastic Surgeon

November 2nd, 2009

Saline breast implants placed over the muscle

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

As you can see from the varied responses, most of us agree that saline implants placed over the muscle can potentially give you a full but somewhat unnatural look. If you have a lot of your own breast tissue to camoflauge the edges of the implant, it will look more natural. Some patients do want it to be obvious that they had implants placed, but for those that want a natural look and prefer saline implants, I would recommend placement under the muscle. Good luck, /nsn.

Nina S. Naidu, MD, FACS
October 28th, 2009

It depends on your soft tissues

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
Sarah,
Saline implants placed over the muscle can look very natural. It is dependent on whether or not you have enough soft tissue (skin, fat and breast) to adequately cover and camouflage the implant. Consultation with a board certified plastic surgeon will determine if you are a candidate. Good luck!
Kenneth R. Francis, MD, FACS
October 28th, 2009

Saline implants above the muscle

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

 Saline implants can be placed above the muscle as long as there is enough soft tissue coverage.  I prefer to place them below the muscle in most patients because they usually do not have enough soft tissue coverage.

Steven Wallach, MD
October 28th, 2009

Don't put saline breast implants above the muscle

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

I have spent the last 20 years implanting thousands of saline and silicone implants. I have been universally disappointed with saline implants over the muscle. If you feel you want to go above the muscle, use a textured, silicone implant. This will give the best anatomic shape with the least chance of ripples. The incidence of scar/contracture above the muscle is too high with smooth saline to make it a less than desirable procedure.

Good Luck.

David A. Dreyfuss, MD

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.