Silicone gel smooth better than Saline
I would recommend silicone gel, smooth walled, above muscle. Mentor has just done research to show no capsular contracture advantage of texturization. Therefore, there is no reason to use them.
Ptosis is better corrected with implants above the muscle.
Silicone looks and feels more natural especially in thin individuals and when the implant is place above the muscle.
I generally prefer smooth over the muscle in your situation but there are trade-offs.
This is a difficult decision but I agree with the majority of other physicians in that the implants are more likely to achieve a better result above the muscle if you are aggressively using your pectoralis muscles (using the pole).
However, as you can see, there is controversy on smooth versus textured. I generally prefer smooth silicone. There is some conflicting data on whether the textured do or do not have a lower rate of capsular contracture. Clearly the textured are more palpable and if they develop a fold or crease it may be prominent and palpable.
We use smooth walled implants over the muscle.
1) For someone like you (athletic, some sagging) in Manhattan, we always place the implants over the muscle.
2) We never use textured implants on anybody. I think they have no advantages and more complications. Smooth silicone implants over the muscle are fine.
Textured, over the muscle for several reasons.
In a very athletic person I would consider nothing but over the muscle. Because it is not really possible to place the implant totally under the muscle (the inferior border of the pectoralis muscle cuts across the middle of the implant and using the serratus muscle laterally and inferiorly is impractical) the implant moves and develops more inferior prominence in athletic people who use their arms. The ideal implant for someone like you with your build is a textured anatomic implant. This gives a normal, natural superior slope and remains as soft as a submuscular implant. Unfortunately, this implant is only available in saline in this country. (In Europe, a textured anatomic silicone implant is the most common implant used.) You, therefore have the choice of that saline implant or a round textured silicone one. As for the “slight ptosis,” the true amount will determine if you will need a mastopexy (lift) or if simply inserting a reasonable sized implant will correct the droop. This, however, is another reason I would not use a submuscular implant in you. By freeing the breast tissue totally off the muscle, it is easier to correct the droop. Only an examination by an experienced breast plastic surgeon can help you decide between saline and silicone and whether you need anything other than the implant to correct the droop.
My vote is over the muscle
Given your athletic build and the fact that you pole dance, an implant placed under the muscle may look unnatural when you dance or lift weights. The muscle tightens and can cause a double bubble effect. If the implant is place above the muscle, the chance of that happening is very very unlikely. However, there is a slightly increased risk of capsular contracture.
I would suggest a silicone implant, smooth, above the muscle. That will also help the ptosis. However, it is hard to recommend above the muscle (which I do not frequently do) unless you are examined. Some patients have very little breast volume and need the implant under the muscle or it may look too superficial. Good luck with your decision.
Textured over muscle implants may show folds
Dr. Baxter is right in saying your decision is one to be based on trade-offs.
Over the muscle silicone smooth is nice, but the larger the implant or the skinnier you are, the more obvious the implant. A textured implant over the muscle decreases incidence of capsular contracture but is very prone to showing folds.
Don't worry about the double bubble, as a crescent mastopexy can take care of positioning your nipple, without a full lift.
Be sure you spend A LOT of time understanding the tradeoffs for each alternative with your surgeon.
There is no single best answer to your question, only a decision based on trade-offs. Under the muscle often looks more natural and may have a lower risk of capsular contracture, but for someone athletic, animation deformities and double bubble are a significant risk. This is related to the way the muscle is cut in order to put the implant under. Over the muscle, on the other hand, often just looks more fake and if the implants are not well supported then you end up with a "rock in a sock" look. Subfascial is something you might want to look into, along with a related technique called split subpectoral. This balances the need for coverage while avoiding the things that cause distortion with muscle activity.
I like over the muscle silicone smooth. If you are a dancer and want large breasts, a large implant might give you the lift you need. Talk to your doctor.
No single answer for breast implants in athletic patients
This question is very common, and unfortunately there is no way to give you just one answer. The correct choice for you depends on several factors and there are pro's and con's with each of your choices.
Your anatomy, degree of ptosis, amount of soft tissue coverage, and choice of implant size all play into your optimal choice.
Most research does indicate a higher contracture rate with above muscle silicone implants, but how that will translate to the newer implants now being used is debatable.
You should really discuss these choices with your surgeon, and if not satisfied, then obtain a second opinion. Good luck!