What Do You Recommend for Me: Saline Vs. Silicone/Under or over the Muscle? (photo)

Received opposing opinions on which I should do! One doctor recommended Saline, plus lift under the muscle and a second recommended Silicone gel, over the muscle. I'm 5 feet and weigh 105 (so very petit) and have 2 breastfed babies (3 and 1 years of age). I would like natural looking (inconspicuous as possible) breasts - in and around the small C/large B size. I do not want a lift!!! Help...what should I do? The more Surgeons I speak to, the more confused I am...

Doctor Answers 10

Silicone breast implants above the muscle

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When I consult with patients who desire breast augmentation but no lift, I evaluate the droop of the breasts. In your case there is droop because you have had several children. It is not severe though, so if you do not want a lift, I think that you can still have a good result. In these cases I tend to place a silicone implant in the sub-glandular/sub-fascial plane. This is above the muscle. This enables the implant to expand the breast envelope to the maximum and can give you a very natural result. I only do this with silicone implants because the saline implants are too palpable and might show visible rippling.You must understand that the result will be a fuller breast with some retained droop (actually quite natural appearing). It will not be a high tight "augmented" look. I hope this helps


Daniel Medalie, MD

Prefer silicone retro-pectoral

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I recommend a new technique called Breast Augmentation with Mini Ultimate Breast Lift.  Using only a circumareola incision it is possible to place the implant, reshape your breast tissue creating upper pole fullness, elevate them higher on the chest wall and more medial to increase your cleavage.  Aligning the areola, breast tissue and implant over the bony prominence of the chest wall gives maximum anterior projection with a minimal size implant.  Silicone gel implants placed retro-pectoral look and feel more natural, are less likely to ripple and are more stable over time.  Since you want a small increase (to a small C/large B) this can be achieved with a small implant, which will give you the best results.


Best Wishes,

Gary Horndeski, M.D.

Recommending Silicone

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For the most inconspicuous and natural look I would recommend a silicone implant under the muscle and without a lift...I think with the right implant it will fill out the bottom pole of your breast nicely and avoid the need for a lift...There is no reason to go with a saline implant in your case!

What Do You Recommend for Me: Saline Vs. Silicone/Under or over the Muscle? (photo)

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Silicone = more natural feel but costs more. Lifting maybe but only in person examination allows a more definitive response. 

What Do You Recommend for Me: Saline Vs. Silicone/Under or over the Muscle?

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Three issues presented face many women consider breast surgery

Breast lift?  Easiest of the three. You do not need a lift.The lower part of the areola is even with or above the breast fold.  That is a normal position. Any skin laxity will be resolved by the implants.

Saline or silicone?  Most patients and surgeons prefer silicone for its more natural feel, and sometimes more natural appearance, as the ripples that can be felt is almost all patients with implants are sometime visible. For a patient with large breasts getting small implants, the difference is small, but for others it is real. 

 Above or under the muscle? Most surgeons in the US prefer below the muscle for almost all patients. Usually, they appear more natural at rest, they are less likely to develop capsular contracture, and they are less likely to conceal lesions on mammograms. They do, however, compress the implants with chest muscle use and cause some motion and distortion. There are patients for whom the pros and cons will lead to a recommendation for above the muscle, but those are uncommon for most surgeons. 

Sorry to add to the confusion, but I would seek at least one more consultation, and look elsewhere from the surgeon suggesting the lift. All the best. 

Jourdan Gottlieb, MD
Seattle Plastic Surgeon

Augment issues

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The decision of whether to go above or below, silicone or saline, make augmentation a complex issue which requires more than one consultation with a plastic surgeon.  I would encourage you to find a board certified plastic surgeon with whom you are comfortable, discuss these questions at length with him and then reach a conclusion.  I do not think that you need a lift at this time.

What to do ? Silicone or saline Above or below the muscle?

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From your pictures you certainly do not need a lift since the NAC is reasonably positioned. I would perform a dual plane augmentation, releasing the lower pole just a bit. Also I would recommend silicone in a thin individual such as yourself who is without much breast tissue. Silicone would diminish the chance of palpation significantly and feel more natural.

Saline Or Silicone Over Or Under The Muscle

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Plastic Surgeon's have to consider many things when making this decision.  An exam and a consultation are needed. Patient's goals, and lifestyle are taken into consideration.  What may seem right for 1 patient, may not be for  another. Find a Board Certified Plastic Surgeon that you trust and are comfortable with.

Opinions will Vary

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Thank you for your pictures. In my opinion you not need a lift. Secondly I would place silicone or saline underneath the muscle. This will lessen the chances of an "artificial" look.  You will decide whether you prefer silicone or saline. The feel is different and the price point is different.  You will ultimately have to trust your instincts on which surgeon/recommendations to go with.

Dr. ES

Recommend for Me: Saline Vs. Silicone/Under or over the Muscle?

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Thank you for the question.

You will find that, like many things in plastic surgery, every doctor will have “strong preferences” about a certain issue. This preference does not necessarily mean that one way of doing things is better than the other. Having said that, often after examining a specific patient and achieving an understanding of her goals, I will be strong opinion as to the best way to help achieve the patient's goals and to  help minimize the potential to “downsides” of  breast surgery.

Each plastic surgeon may have his/her opinion that is based on their specific/unique education, experience, and personal preferences. Their opinions may also be shaped by unfavorable results they have encountered in their practices.

Although these different opinions can be confusing and a source of anxiety for patients, it is good for patients to understand the different options available. Ultimately, it will be up to each patient to do their due diligence and select their plastic surgeon. Part of this selection process will involve the patients becoming comfortable with the plastic surgeon's experience level and abilities to achieve their goals as safely and complication free as possible.


There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”.    I will try to outline some of the differences here;  you may find the attached link helpful as well.

I think it is in the best interests of most patients seeking breast augmentation surgery to have implants placed in the “dual plane” or sub muscular position. This includes athletic patients.
The submuscular positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look  of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability  of the implants (which may increase with time, weight loss, and/or post-pregnancy changes).

The submuscular positioning  also tends to interfere with mammography less so than breast implants in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position.

On the other hand,  sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants  seen with flexion of the  pectoralis major muscle)  they can be seen with breast implants placed in these sub muscular position. 

Overall,  after considering pros/cons carefully, I find that there are many  advantages to placement of breast implants in the sub muscular ( dual plane) position.

Generally speaking,  the type of implant used may  determine the final outcome for some patients, especially if the patient does not have significant covering breast or adipose tissue. For example, most surgeons feel that silicone implants have a more natural look and feel than saline implants because silicone gel has a texture that is similar to breast tissue.

Each patient differs in the amount of breast tissue that they have.  If a patient has enough breast tissue to cover the implant, the final result will be similar when comparing saline implants versus silicone gel implants.  If a patient has very low body fat and/or very little breast tissue, the silicone gel implants may provide a more "natural" result.

On the other hand, saline implants have some advantages over silicone implants. Silicone implant ruptures are harder to detect. When saline implants rupture, they deflate and the results are seen almost immediately. When silicone implants rupture, the breast often looks and feels the same because the silicone gel may leak into surrounding areas of the breast without a visible difference.  Patients may need an MRI to diagnose a silicone gel rupture.   Saline implants are also less expensive than the silicone gel implants.

Other differences involve how the breast implants are filled. Saline implants are filled after they’re implanted, so saline implants require a smaller incision than prefilled silicone breast implants.
  Also, saline breast implants tend to be less expensive than silicone breast implants.

My best general advice for patients seeking to undergo breast augmentation surgery is:

1. Concentrate on choosing your plastic surgeon carefully.  Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you're looking for. Ask to see lots of examples of his/her work.

2. Have a full discussion and communication regarding your desired goals  with your plastic surgeon. This communication will be critical in determining which operation and/or breast implant size/type/profile will most likely help achieve your goals.
In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural” o "B or C cup" etc means different things to different people and therefore prove unhelpful.
 Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also be inaccurate.

3.  Once you feel you have communicated your goals clearly,  allow your plastic surgeon to use his/her years of experience/judgment to choose the breast implant size/profile that will best meet your goals.  Again, in my practice, this decision is usually made during surgery.

Overall, based on your photographs, I would suggest the use of silicone gel breast implants placed in the sub muscular position. No need for breast lifting.

I hope this, and the attached link, helps.

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.