Saline implants over the muscle - can this be done without looking fake?

Question

I would like to do saline implants due to concerns about silicone. I know a lot of doctors say it's safe but I just feel way more comfortable with saline. The issue is I also want to do them over the muscle because I'm extremely active (can do 15 pull ups). Are there any successful cases of saline being placed over the muscle, maybe with fat grafting too so it doesn't look fake? I am a B cup with a wider rib cage for context.

Chet Mays, MD · Answer

Hi, Thank you for your injury. We would love to sit down and talk with you about your concerns. Schedule a appointment with a Board Certified Plastic Surgeon to help you reach your goals.

Daniel Barrett, MD · Answer

Dear Adventurous287575,

the two main types of implants are silicone and saline. The shell of the implants can be either textured (which reduces capsular contracture) or smooth. A textured implant sometimes requires a larger incision. The shape of the implant can be either round or tear drop shaped (gummy bear). Both have their advantages and disadvantages.

The different types of implant offer different pros and cons. For instance, the pros of silicone implants are that they look and feel more natural and ripple less.

On the other hand, the pros of saline implants are that they do not require as large of an incision as silicone, less expensive, they have less incidence of capsular contracture (scarring around the implant), one can tell immediately if there is a rupture, the size can be slightly adjusted, and they can be used for women less than 22 years of age.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Christine Rodgers, MD · Answer

Hello, Adventurous287575! Utilizing saline implants are going to provide a less natural appearance compared to silicone. Going under the muscle can help give a more natural result and not everyone gets an animation deformity if that is your concern. It is definitely a possibility to do saline above the muscle though. It also depends on what amount of breast tissue you are starting with and your anatomical features. Fat grafting is also an option but this is not a long-term solution. However, I would recommend consulting with a board certified plastic surgeon in person and review before and after photos. Best of luck on your surgical journey!

Luis A. Mejia, MD · Answer

Dear Adventurous287575, thanks for sharing your concerns, to avoid any kind of thought about implants another option is to simply touse your own fat instead of implants. Make sure you go on consultation with a board-certified plastic surgeon. Hope this helps and best of lucks. Dr. Luis Mejia

Ira H. Rex III, MD · Answer

Saline implants can look quite natural over the muscle, but it depends on a number of things.  If you pinch yourself in the area of the upper pole, and there is only a little fat, say less than about an inch, then the implant is more likely to be visible.  Also the amount of salt water fill may give it a hard balloon appearance versus a natural teardrop.  One of the major concerns is that visible rippling is much more common in this area when the implants are over the muscle.  Toe there may be a number of benefits of going under the muscle for certain women.  This is something to discuss with your plastic surgeon so you can make a decision regarding the advantages and disadvantages of this.

Ted Eisenberg, DO, FACOS, FAACS · Answer

crown body builders with sale behind the muscle who can still do all the "ups". I recommend an in person consultation with a plastic surgeon to discuss your goals and be measured. After I measure and discuss goals with my patients, we then look at pictures of women (my patients) with similar measurements with different size and style breast implants. They also get to see what they would look like when the breasts have fully dropped and fluffed and in clothes. You get to see actual results and the surgeon's experience and not a virtual idea of what can be achieved. Women tell me that this process is very helpful in determining what size and style breast implant is right for them. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Michelle Zweifler, MD · Answer

Implants can be placed either above or below the muscle. Above the muscle can have a higher incidence of capsular contracture, rippling and palpable implant edge. Fat grafting can help minimize palbability. Individuals that are exceedingly active, tend to prefer subglandular. Saline or silicone is a patient decision on their comfort level.

What makes implants look fake? Usually it's implants that are too big or have capsular contracture distorting the breast.

What makes implants look fake?  Usually it's implants that are too big or have capsular contracture distorting the breast.

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation (“overs”):

•	Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster 
when compared to subpectoral augmentation.

•	Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).

•	Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.

•	Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.

Subpectoral Augmentation (“unders”):

•	Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.

•	Subpectoral implants have a lower rate of capsular contracture.

•	Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.

•	The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other.

With regards to your specific question, the general rule of thumb for avoiding the "fake" look is conservative sizing.

As always, your board certified plastic surgeon can help guide you in your decision making process.

Harry T. Haramis, MD, FACS · Answer

In my experience, for active athletes, body builders, implants over the muscle works well.

Gel are less likely to ripple when placed over the muscle than salimes.

Fat grafting by itself (w/o implants) is also an option.

An exam and consultation with a plastic surgeon is recommended to discuss your best options and expectations.

Robert M. Tornambe, MD · Answer

I appreciate your concerns and I have performed breast augmentation on many serious bodybuilders. Depending on each individuals specific anatomy, the implants can be placed above or below the chest muscles and still look natural, even while working out. If your breasts are very small, and there is little breast tissue, placement of saline implants over the muscle may show rippling of the skin, which is undesirable. Fat grafting may be an option, however, placement of the saline implants under the muscle would probably be a better choice. Come see me or another board certified plastic surgeon in our area to explore the best options for you. Good luck.