Thanks for your question, and despite my headline, I am sympathetic and understand your work and activity limitations. It's just that your "solution" is the wrong one, IMHO.First off, you have "very small breasts" and above the muscle implants (any kind) will have a higher likelihood for showing edges or ripples. Saline would be the worst, cohesive silicone gel less so, and textured teardrop-shaped implants, well, less ripples but more likely to feel or see an "edge." Plus, they are more firm.We also know that above the muscle has a higher chance for capsular contracture, so someone who has limited time off certainly doesn't want a re-operation to have capsulectomies and new implants, do you? (Not only the time off, but the cost, even though Sientra has a nice CC "warranty program. Do you really want to burn another 3-4 weeks' vacation and time off, and do you really think the re-operation is "free"?)In the past I would have agreed that above the muscle healed faster (I have been doing breast augmentation for 27 years, and started doing them above the muscle, but since the FDA restrictions of 1991 have learned that below the muscle has less CC and if done carefully with minimal tissue injury, the pain is no greater than with above the muscle placement). But now, with precise pocket creation and meticulous hemostasis (control of capillary bleeding points), there is very little swelling, almost no bruising, and pain is typically described as a 2 or 3 on a 10 scale. Honest!Some surgeons have gone so far as to call these (standard, careful) techniques the "overnight recovery" or "Flash recovery" or "No pain" breast augmentation as if they are the sole provider of magical skills that allow you to circumvent the normal physiology of healing and activity restrictions! Careful surgery, meticulous hemostasis, "no touch" Keller Funnel implant insertion, and simple attention to detail will make even submuscular augmentation as minimally uncomfortable as above the muscle. Sloppy technique, blunt dissection, drains, Ace bandages or tight surgical bras designed to reduce bleeding (instead of meticulous control of bleeding points in the operating room) will cause bruising, swelling, and pain whether the implants are above OR below the muscles, and with these surgeons, below the muscle is indeed more painful.But you actually said "heal faster" not less pain, and collagen formation, sealing of blood vessels, softening of stretched breast tissues (and muscles if below) all take the same time for most all individuals. No one heals overnight or in a weekend, no matter which surgeon does the surgery. Again, careful, meticulous technique is the key, not a "named" surgical procedure! Or location of the implants above or below. Tissues still have to heal, regardless of implant position.Now, on to your next misconception.Teardrop-shaped implants (above or below the muscles) must be textured to adhere to tissues and keep them in the proper orientation (because upside down would look really weird, right?). This means that these implants don't drop slightly to the side and flatten out as normal breasts do when reclining. They still point upward in that same sloped appearance. "Real" breasts flatten and round out when reclining, and are teardrop shaped only when standing, which is exactly what smooth round implants do--teardrop shaped when standing, and flatten out and slide slightly to the side when reclining. So, the teardrop shaped implants are NOT "anatomic" at all--they are just teardrop-shaped in every position.Plus, they are more firm than smooth round cohesive silicone gel implants, they require a longer incision to insert, and they cost more. Which of those do you like?Don't get me wrong, teardrop shaped high-strength cohesive gel implants are fine products in select patients (I think they are best for some cases of reconstruction after cancer surgery and in cases where multiple surgeries have destroyed the shape and "salvage" is being attempted.But for someone who is trying to get back to work and activities ASAP, smooth round cohesive silicone gel implants (Sientra makes wonderful ones) below the muscles (by a surgeon who understands careful and precise technique and meticulous hemostasis) will give you the softest, most natural result and the lowest chance for re-operation (above the muscle has a higher CC risk). And will cost less. Just to let you know, when I do this surgery several hundred times per year, I use not only the careful surgical techniques I have been discussing, but also oral anti-inflammatory (Celebrex) and muscle relaxant (Robaxin) medications, and IV Decadron (steroid to reduce swelling, stabilize cell membranes, and diminish nausea), as well as long-acting local anesthetic (Marcaine with epi) in the implant pockets, and extended-release local anesthetic (Exparel) in the tissues around the breasts for 3-day pain control. This means that oral pain pills (prescribed, but often not needed) are less likely to cause nausea and vomiting, which is already limited by the use of TIVA anesthesia rather than "standard" inhalation anesthetic gases and nitrous oxide. The latter has a 7-28% nausea rate, but TIVA in our accredited (AAAASF) surgical facility has a 2.5-3.5% nausea rate, leading to quicker return to normal activity.Choose quality, not quick and easy! You are planning to have these implants for a while, no? Best wishes and Happy Holidays! Dr. Tholen
