"Perky" means different things to different patients. No one can tell you how to achieve your desired breast appearance without an in person examination. There are multiple options that can produce a cosmetically acceptable result depending on your desired outcome: an implant alone in front of the muscle or a dual plane placement of the implant, an implant and a minimal lift with an incision just around the areola, or an implant in front of the muscle, dual plane or behind the muscle and a greater lift. Each would result in a different degree of improvement. Keep in mind that following advice from a surgeon on this or any other website who proposes to tell you exactly what to do and how to do it based on limited two dimensional photos without examining you, physically feeling your tissue, assessing your desired outcome, taking a full medical history and discussing the pros and cons of the operative procedure would not be in your best interest. Natural appearing results need to be individualized and what is appropriate for one patient is not necessarily the best for someone else. I would suggest that you find a surgeon certified by the American Board of American Plastic Surgery and one who is ideally a member of The American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person. Robert Singer, M.D., FACSLa Jolla, California