Above or Below the Muscle for Saline Implants? Differences?

I'm 5'-6", 116 lbs and I want to know what is better, above or below the muscle for saline implants?...and would like to know what the differences are, if any?

Doctor Answers 10

Above or Below the Muscle for Saline Implants? Differences?

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Hello! Thank you for your question! Breast augmentation is a procedure often sought by women to increase size, add upper pole fullness and projection along with improve shape and symmetry of her breasts. Women who have the breast augmentation done report increased self-confidence, self-esteem, and more comfortable with her body. In fact, it has been the most popular procedure in plastic surgery in the US for the past few years. In general, implant size does not correlate with cup size. The cup size itself will vary from manufacturer to manufacturer as well as who is doing the actual measurements. Thus, cup size or implant size is never a reliable indicator for your breast size. I typically encourage my patients not to communicate her desires in cup size but more on the actual look and appearance. Your breast width is the most important measurement.

Things to to consider during your consultation, which your surgeon will discuss with you, include implant type (saline vs silicone), shape/texturing of implant (round vs shaped/textured vs non-textured), implant position (sub pectoral, subglandular, or subfascial), incision (inframammary fold, periareolar, axillary, or TUBA), and size of implant. This can be performed with/out a breast lift, which would serve to obtain symmetry in breast size or nipple position as well as improve shape. Good communication between you and your surgeon of your expectations is warranted - choosing your surgeon wisely is the first step. Discussion of your wishes and having an honest and open dialog of your procedure is mandatory. I have found that photographs brought by the patient is helpful to get a visualization of the appearance you wish for in terms of size, shape, fullness, etc. In addition, your surgeon's pre and postoperative photographs should demonstrate a realistic goal for you. Once this has been accomplished, allow your surgeon to utilize his/her best medical judgment during the procedure to finesse the best possible result for you after preoperative biodimensional planning and fitting the right implant for your breast width. Too large of implants for the woman often destroys the breast pocket and breast shape, thus creating an oft seen uncorrectable problem later. Very slightly less tissue may be visualized with subglandular implants, but not very significant.

Implants may be placed either in the subpectoral (beneath muscle) or subglandular/subfascial (above muscle). Both locations are excellent and you can choose either one - your surgeon will discuss the pros and cons of each. In general, while a placement above the muscle is a more natural position for an implant to augment the actual breast, I find that it is not desirable for very petite women or women with a paucity of breast tissue - as the visibility and potential rippling seen/thinning of tissue may give a suboptimal outcome. A subpectoral pocket adds additional coverage of the implant, but causes slightly more and longer postoperative pain/swelling as well as the potential for animation deformity with flexing of the muscles. Today, there is no virtually no difference in rupture rate, capsular contracture rate (slightly higher with subglandular as well as certain incisions), and infection with the positions. As you see, there are a few factors to decide upon for incision, placement, and implant type/size. Consult with a plastic surgeon who should go over each of the options as well as the risks/benefits.

Hope that this helps! Best wishes for a wonderful result!

Scottsdale Plastic Surgeon
5.0 out of 5 stars 28 reviews

Saline implants below the muscle

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There are some basic differences between placing breast implants above or below the muscle. I prefer to place implants below the muscle to achieve a more natural appearance. Saline implants are more likely to ripple and placing the implants under the muscle provides an added layer of camouflage.

For low body weight, place saline implants UNDER the muscle

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SEE VIDEO BELOW FOR OVERVIEW>>>>There are numerous previous responses which have answered this qeustion. However, the brief answer to your question, in my opinion, is a strong recommendation for under the muscle due to your being typically under weight for your height.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

Salines should always be below the muscle

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Because of increased wrinkles and ripples with saline above the muscle, they should ALWAYS be below the muscle in my opinion.

Saline above or below for implants

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Most of the patients I see are pretty thin.  Usually I place them under the muscle to offer more soft tissue coverage in the superior pole.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Saline implants above or below the muscle?

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I prefer implants above the muscle if you have enough tissue in the superior chest. My reasoning is that they are less likely to leak, do not move with arm movement and are less likely to displace late. A major reason for submuscular implants is that they stay softer than subglandular implants, unless you use a textured implant. A textured implant has the same incidence of feeling firm whether above or below the muscle. The reason most surgeons use below the muscle implants is that it is an easier procedure than using a textured implant. If you have thin tissues, then I use a silicone implant above the muscle. With saline, I have the option now of using a shaped implant that can give very natural results. With really thin tissues you should have a submuscular implant for the most natural result.

Robert T. Buchanan, MD
Highlands Plastic Surgeon

Saline implants should usually be under muscle

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Saline implants should almost always be placed under the muscle in order to provide better coverage for the implant and a more natural look.  Saline implants above the muscle will usually have a lot of rippling, especially in someone your size.  Even with a implant below the muscle, you should really understand the pro's and con's of saline vs. silicone.  Good luck!

Dean Fardo, MD
Atlanta Plastic Surgeon
4.7 out of 5 stars 15 reviews

Go under the muscle with saline implants in a thin patient

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One of the more important reasons to put implants under the muscle is for coverage. With ample breasts and thicker body fat layer, it doesn't make much of a difference but it does not sound like you are in that category. Even with going under the muscle though, saline implants will not feel as natural as silicone gel implants, and keep in mind that the muscle does not cover the lateral sides or the bottom.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 59 reviews

Placement of Saline Implants

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I think saline implants should almost always be placed under the muscle.  They ae more likely than silicone implants to develop wrinkling.  By placing them under the muscle the rippling can be somewhat hidden.

John Whitt, MD (retired)
Louisville Plastic Surgeon


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Very few women who require implants look attractive with over the muscle saline breast implants. The reason? ALL breast implants, but especially salt water (saline) implants ripple and pleat. To prevent these ripples from being seen and felt Plasticsurgeon want to put as much soft tissue cover on the implants as possible. If the woman does not have a lot of breast tissue to cover the implant, the underlying pectorals major muscle needs to be used to provide cover as well. In addition to less rippling and pleating of the implants, submuscular implant placement is associated with a lower risk of scarring around the implants (less capsular contracture) and easier mammography diagnosis of breast masses. In a thin woman the vast majority of Plastic surgeons would advise a submuscular breast implant placement. Hope this helps. Dr. Peter A. Aldea

Peter A. Aldea, MD
Memphis Plastic Surgeon

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.