Will over the Muscle Saline Breast Implants Look Natural?

Question

I am naturally a 34B and am getting Saline breast implants. The doctor says I have enough breast tissue to go over the muscle, but I'm just not as familiar with it.Will they look as natural as going under the muscle?

Lewis Albert Andres, MD · Answer

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!

Otto Joseph Placik, MD · Answer

I generally prefer smooth implants placed under the muscle using an incision around the areola or under the breast.   Reasons are:

	1)more tissue covering the implant for a more natural look.

	2) improved mammograms when compared to the subglandular implants.

	3) decreased rate of capsular contracture. I reserve the textured implants for patients with capsular contracture or in patients with significant breast tissue and ptosis requiring a subglandular placement.

Michael Kulick, MD, DDS · Answer

Maybe or maybe not.  I prefer to use saline implants but do put them under the muscle.  
Looking natural depends a great deal on your expectations.  Then, there is the amount of breast tissue - you and your doctor are OK with this - and the amount of subcutaneous fat.  If you have "enough" of the above, then you should be OK with above the muscle placement.  It is less painful after surgery - that's a plus vs putting the implant under the muscle.  "Rippling" of the implant can be minimized to a degree with a maximum fill of the implant.
If your not familiar with the treatment plan, you should talk with your doctor again or at a minimum, see another doctor.

Jeffrey Weinzweig, MD, FACS · Answer

Saline implants can be placed either under the muscle or above. When the implants are placed under the muscle they tend to give a more natural appearance because there is more tissue covering them. However, in someone who has an adequate amount of breast tissue to begin with, it is absolutely fine to place the implants above the muscle and anticipate a very natural result

Steven Wallach, MD · Answer

Decidiing on the pocket location for implant placement really depends upon the anatomy.  I prefer under the muscle in most patients to add more soft tissue coverage.

Kent V. Hasen, MD · Answer

Saline breast implants can be placed either above the pectoralis muscle or below it. Even when the implant is considered under the muscle, the bottom 1/3 of the implant is truly not under the muscle and the entire outside of the implant is only under the breast tissue itself. That is where patients complain of the rippling and palpability of the implant after a saline breast augmentation if they are very thin or have very little breast tissue. Saline implants can be placed above the muscle in situations where the patient has a good amount of soft tissue (either breast or fat) at the top of the breast. I use a caliper to pinch the tissue in the top portion of the breast to best assess this. Addtionally, when the implant is placed above the muscle, I usually lift up the thick coating over the muscle called the fascia. This allows for additional coverage of the implant at the top and medially near the sternum. This helps cut down on an unnatural appearance and rippliing. There are benefits of being in this "subfascial" plane rather than under the muscle. The 2 biggest are that the implant will not move and possible distort the breast with contraction of the muscle and second the initial surgery is less painful with an easier recovery. Your consultation with your surgeon will best help assess which pocket and size of implant would be best for you.

George J. Beraka, MD (retired) · Answer

Hi!
It really depends on the details of your anatomy.  In New York, we do occasionally place saline breast implants over the muscle in selected patients, and they look natural.
You need to trust your surgeon.  Get another opinion if you are not sure

John Whitt, MD (retired) · Answer

Saline implants placed btween the breast and underlying muscle have the greatest chance of appearing abnormal. Saline implants have a higher rate of wrinkling. If they are placed under the muscle, the muscle can hide the wrinkling somewhat. I think that you would probably be happiest with silicone implants placed under the muscle. If you have concerns, you should address these with your surgeon.

John E. Gross, MD (retired) · Answer

In the United States the majority of saline implants are placed beneath the pectoral muscle.  Saline implants, which tend to wrinkle or ripple a bit more than traditional gel devices look more natural with more of your native tissue covering them.
Your surgeon will assess the thickness of your natural tissues, and if considering above the muscle the thickness in the upper portion of the breast seems most critical to a natural result. in patients that are thin up top, the extra layer of tissue provided by the pectoral muscle helps camouflage the transition from your upper chest to the upper edge of the implant
If you are unclear on the reason for the suggestion for that location go back for another visit.  If still unclear you may want to seek another opinion.

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