You hit the nail on the head. Glad to see you have done your homework. Saline implants are perfectly safe and have never been removed for the marketplace. Placing the implant under the muscle gives a more natural look to the upper portion of the breast. Moreover, it is safer for you to have them placed under the muscle. That having been said, it does hurt a little more as your chest muscles will be stretched and quite tender for a few days as you accommodate to your new breast volume. Excellent choice. I wish you well.
Saline Breast Implants: Natural contour and Improved shape with submuscular implants
Breast implants can be placed in the submuscular or subglandular plane.
A natural contour and feel is dependent on the following breast principles:
- Symmetry of the breasts
- Position of the nipple areola
- Shape of the native breast prior to implantation
- Contour of the breast prior to implantation
- Quality of the skin
- Amount of breast parenchyma
- Density of breast parenchyma
- Technique of implantation
- Saline or silicone implants
Saline implants can feel very natural depending on the quality of the skin, size of the implant relative to the breast, location of the implant, and density of breast parenchyma.
Saline Breast Implants can Look and Feel Natural - Look at the Photos!
My breast augmnetation gallery includes more than 90 of my breast augmmetation patients with views from three different perspectives. A number of the images are women with saline breast implants. See link below.
Having practiced plastic surgery in the 'breast augmentation capital of the world' (Los Angeles), I have developed some fairly strong opinions about this operation. In thinking about breast augmentation surgery, I believe that the most important question for a prospective patient to ask themselves is this: Am I seeking a natural-appearing result? When the goal of this operation is a natural breast enhancement, the results can be absolutely beautiful.
However, if the goal is to create a breast profile which is out of proportion to a woman's body, the results (by definition) never appear natural, and these patients not infrequently end up having a series of operations to address problems with their abnormal appearance. For that reason, I encourage women who are investigating breast augmentation to consider a breast implant size that will help them 'fill out clothes better' and improve the overall proportions of their body, not one that makes them look like "the gal with the boob job".
Quite a number of my breast augmentation patients are moms. After one or more pregnancies, most women experience a loss of breast volume combined with some 'stretching out' of the breast skin. In many of these patients, a breast implant of moderate size will restore a very pleasing breast contour. These patients are NOT looking to raise eyebrows at work or around the neighborhood - they just want to throw their padded bras away, and to feel better about their appearance in private.
When there is laxity of the breast skin that makes the breasts appear somewhat droopy, the addition of a breast implant of moderate size can 'fill up' the excess skin and create the appearance of a breast lift (although this is not truly a breast lift or 'mastopexy'). This is often a situation that exists after pregnancy and lactation, but I also see quite a number of patients with significant breast skin laxity who have never been pregnant. In patients with more advanced drooping of the breasts, particularly when the nipples are pointing downwards instead of slightly upwards, a mastopexy (breast lift) needs to be combined with the breast augmentation surgery to tighten the skin envelope of the breasts, in order to produce a result that is truly youthful and aesthetically ideal. This procedure is called an augmentation mastopexy, and the results of this operation can be dramatic and absolutely transforming. It is discussed in greater detail as the next topic under the heading 'Body Contouring Surgery'.
Attention to detail
While the issue of 'over' or 'under' the pectoralis major muscle receives a great deal of attention, even more important than breast implant position relative to this muscle is implant position vertically and horizontally on the chest wall. In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness.
In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that a breast implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear 'bottomed out', with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast - another situation with a distinctly unnatural appearance.
The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Excessive lateral dissection of the implant pockets will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. Inadequate lateral dissection, on the other hand, will result in an augmentation with an abnormal 'side by side' appearance. As it is lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an 'hourglass figure', careful attention must be paid to ensure that lateral breast projection is not inadequate.
Another consideration is that the breast implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient that is 5'3" will be inadequate for a large-framed patient that is 5'10". Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast augmentation.
Choosing the breast implant size
In consultations I listen carefully to each patient to ensure that I clearly understand their goals for breast augmentation surgery. Based on that discussion, and on the physical examination, I go into surgery knowing what the ideal volume should be within two or three breast implant sizes. However, the patient and I do not decide on one particular size prior to surgery. There is absolutely no way, in my opinion, to know exactly what size implant is the ideal size for a particular patient in advance of creating the implant pockets in the operating room. For that reason I keep a wide range of implant sizes on hand in the surgery center.
If natural is the goal, then the way to get the size right is to 'try out' different implant volumes in the operating room. Once the implant pockets have been created, I place a 'sizer' in one implant pocket and have the upper half of the O.R. table raised so that the patient is in an upright 'sitting' position (chest fully upright). The sizer is then inflated gradually to the point that the breasts appear full, but not unnaturally so. In this manner the exact volume that produces a full but natural breast profile is determined.
For any patient there is obviously a range of implant volumes that would be considered natural. While one patient may seek an augmentation that is 'the small side of natural', another may be interested in something that is more on 'the large side of natural'. By using breast implant sizers to determine exactly what breast profile a given implant volume produces in the O.R., I am able to provide patients with the closest possible approximation of their preoperative goals.
Saline breast implants of a moderate (and in my opinion, appropriate) volume look and feel natural. The implant sizes I most commonly use blend in nicely with existing breast tissue, and patient satisfaction is high. In the ten years I have been using saline implants I have yet to have a patient with saline breast implants return to say "I'm not happy with these, take them out and put silicone gel implants in their place."
Saline implants usually look and feel natural
The result of breast implant surgery has something to do with the patient and her desires regarding size and something to do with the surgeon and his/her technique. If you have relatively little breast/chest muscle tissue and want really large breasts, you are not going to look (or feel) so natural. How natural things look has alot to do with how much of your tissue covers those implants. Think "under the muscle" implants to get that tissue working for you.
If you are more interested in a natural appearance than a particular size, then by all means tell your surgeon. Many surgeons are so used to hearing complaints that the implants are not big enough, that they put large implants in almost by reflex.
The key is to have a good dialogue with your surgeon and to choose a good one. In this case most patients are quite happy.
It depends on your body type
In my practice, 80% of patients select gel implants because the "feel" of the implant is of paramount importance. 20% go with saline because they believe it is "safer" for them. So, if despite all the evaluations by the FDA, you don't feel comfortable with gel, you should go with saline recognizing that they won't (even under the muscle) feel as natural as gel. It becomes a matter of what your personal priorities are.
If you are thin and have minimal breast tissue, the palpable differences between the gel and saline are even more notable. This is especially true when a saline patient (even under the muscle) leans forward and feels the outside edge of the implant. They will almost always feel and or see wrinkles and ripples there. If that would bother you, go with gel.
Saline implants can look and feel very natural when properly done
Thank you for your question!
First, I would like to bring to your attention the fact that breasts must follow a set ideals to be classified as natural.
Natural breasts have the following characteristics:
- The areola – dark pigmented region around the nipples – should not be large relative to your nipple
- The nipple should be above the breast fold – inframammary fold
- The 2 nipples should form an equilateral triangle with the notch of your breast bone
- The breasts should not be sagging
- The nipples should sit directly behind the part of the breast that projects the fullest
- The breasts should appear symmetrical
A recent study by Dr. Mallucci and Dr. Branford, titled “Shapes, Proportions, and Variations in breast Aesthetic Ideals,” gives us 4 set of ideals in beautiful and natural-looking breasts. They are as follows:
- An upward pointing nipple (angled at 20 degrees)
- A slope in the upper pole of the breast
- A tight curvature (convexity) in the lower pole of the breast (i.e., below the nipple)
- An upper pole to lower pole ratio of 45:55 (i.e., the percent of fill below the nipple should be 55% compared to 45% above the nipple)
If your breasts meet these ideals and those I mentioned above, they will look natural.
That being said, there are many factors that go into creating natural-looking breasts, and a combination of the right choices contributes to achieving the desired result. I mention some of these factors below.
1) The size of the implant – a large implant that exceeds your breast boundaries, or overly stretches your breasts, or is too round will make your breasts look unnatural. In fact, there is higher likelihood of bottoming out (i.e., an empty upper pole, nipple sitting too high on the breast), double bubble deformity, implant malposition, implant visibility, breast sagging, and breast tissue wasting. So going big is good, but going beyond limits will get you in big trouble…pun intended.
A board-certified surgeon will always determine a suitable range for the implant volume after conducting some breast measurements. Measurements such as breast base width, the amount of breast skin stretch, nipple to breast fold distance under maximal stretch, skin quality, chest wall asymmetries, etc. will be looked into. For example, if your breast base is very wide, we will require a higher implant volume to avoid the “rock in a sock” appearance.
2) The profile of the implant – How much the implant protrudes or sticks out in the forward direction influences how much stretch is put on the overlying breast skin, and excessively stretching the skin results in negative consequences.
3) The shape of the implant – majority of surgeons prefer round and smooth implants, but if your breasts do not have a natural shape to begin with as we see in patients who have tuberous breasts, then you may require the use of anatomic implants whose lower half is more loaded in volume than the upper half corresponding with the desired natural look.
4) Incision placement – incision location not only determines the degree of trauma to breast’s soft tissues, exposure of the implant to breast’s endogenous bacteria, pocket visibility and control, but also the implant’s position vertically and horizontally relative to the chest wall. For example, compared to the tranaxillary (armpit) or the areola (around the nipple) incision, the inframammary (IMF) incision better allows your surgeon to lower the inframammary fold to increase its distance from the nipple. In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness. I need you to realize that an overly full upper pole will make it obvious that you got implants to enhance your breasts.
5) Pocket – Now to answer your original question, the decision to go behind the muscle or above the muscle has to do with the amount of soft tissue coverage – “padding” under the skin. Choosing a pocket that is tight with sufficient soft tissue coverage not only prevents implant visibility, palpability, and risks of excessive stretching on the breast, but also excessive implant movement into the outer or inner sides of the breasts. A hand-in-glove fit for the implant allows for a natural and long-lasting result. Your surgeon will do a pinch test in the upper pole of the breast to see how much “padding” you have. If you have less than 2 cm, then you do not have much padding and it would be best to go under the muscle. Generally speaking, if your ribs are visible under the muscle, then you do not have much “padding.” If however, you have more than 2 cm, then you have the option to go over the muscle or under the muscle. Under the muscle placement of the implant will provide a more natural look because the muscle helps to maintain a slope for the upper pole while allowing for a curvature in the lower pole. If you are hoping to fully preserve the functionality of the pectoralis major muscle due to athletics or body building, or if you have a shapeless, constricted, tuberous, sagging breasts, and do not have a proper cleavage, then over the muscle may be a better option. Over the muscle (subglandular) implant placement may cause tissue wasting, interference with mammography, hold higher risk for capsular contracture and synmastia (disappearance of the cleavage gap).
Now to answer your original question about what allows a more natural look and feel, saline or silicone? It depends, but before a definite conclusion can be achieved, the filler option has to be analyzed in relation to your breast characteristics, your values and preferences, and desired looks.
1) Saline Implants
Since they come in a non-inflated form, the implant can be inserted without having a large incision on the skin and this results in minimal scarring adding to a natural look.
The non-inflated form also allows the implant to be placed through all incisions including the transaxillary incision which is referred to as the “scarless technique” because there is no scar on the aesthetic unit of the breast itself.
Saline implants have a 1%/year chance of spontaneously deflating (10% chance after 10 years), and although no one can predict when this will happen, it can be embarrassing if this happens while at a party or at work to due sudden changes in breast size.
Saline may not make the breasts feel natural because it is not compressible – there will be a strong resistance when you squeeze your breasts making them feel firm rather than soft and squishy.However, the difference in feel compared to silicone disappears with the amount of breast tissue you have. Special care should be taken on choosing the right size and shape so that they are proportionate with your overall body contour.
Saline implants have higher chance of rippling (wrinkling) which may be visible if you have less soft-tissue coverage (i.e., soft tissue refers to your skin, fat layer beneath your skin, and the breast tissue). The thinner you are the more you see it. Rippling often develops on the outer perimeter of the augmented breasts: on the side, bottom or in between the breasts. It can be caused by under-filling of the implant. Solutions would be to choose a moderate sized implant, choose behind the muscle implant placement, choose smooth surfaced implant, and gain weight. That being said, visible rippling can occur with saline implants even behind the muscle on the lateral (outer) aspects of the breast near the breast fold when you lift your arms, or lean forward.
Silicone as a filler will make the implant feel softer resembling the feel of the natural breast tissue due to its gel-like cohesiveness. This characteristic also makes the implants less detectable even by touch or feel.
Silicone implants are ideal for thin woman with small breasts
Silicone implants experience minimal rippling which is barely visible and may occur mostly when patients lie down on their breasts
Silicone’s cohesive gel allows more a greater variety of implants – i.e, shaped implants are only silicone-based and provide a natural look which is helpful in treating certain conditions related to the chest wall or breast development.
Silicone implants have a 1%/year chance of rupturing similar to saline implants (10% chance after 10 years), however, the rupture is silent which means that the breast size will remain stable. The downside is that you will require an MRI test to diagnose the gel leakage/rupture.
Silicone implants cannot be safely introduced behind the breast through the transaxillary incision unless they are small or moderately sized.
Silicone implants appear in pre-filled form which means implant insertion requires a longer incision on the skin to prevent damage it, and its volume cannot be manipulated.
The New Silicone Implants:
There is often a concern over safety and monitoring of silicone implants, but these implants have a similar complication rate compared to saline implants, and several clinical trials have shown the safety and longevity of silicone implants that allowed them to be approved by the FDA since 2006. Please note that today's 5th generation silicone cohesive gel implants have been proven to be very durable and safe. In fact, they have lower rates of capsular contracture and gel diffusion. These 2 things were the major concern from previous silicone implants. The new silicone implants also have thicker shells, wider variety of surface textures, and implant shapes.
Verdict: You may want to consider Silicone implants if your primary concern is a natural looking result.
Hope this helps!
Saline Implants Have the Potential to Look & Feel Natural Following Breast Augmentation
Saline implants have the potential to look and feel natural following breast augmentation surgery. This requires adequate soft tissue coverage of the implant and the selection of an appropriately sized implant.
When adequate soft tissue coverage is present, the breast looks and feels natural. When soft tissue coverage is inadequate, the breast may not feel normal and rippling may be present.
Adequate soft tissue coverage is more likely if the patient has a moderate amount of her own breast tissue and the implants are placed underneath the muscle. Under these circumstances, the breasts are more likely to feel normal and also have less rippling. The use of large implants would have the opposite effect because the soft tissue coverage would be inadequate.
In patients who have minimal breast tissue and a thin body habitus, an artificial feel and rippling may be unavoidable. In this situation, silicone implants in a submuscular position may be necessary to obtain a natural look and feel.
A consultation with a board-certified plastic surgeon will help determine the appropriate style and size of breast implant. In your situation, it would not be unreasonable to expect a natural feel and look with saline implants. With a reasonable starting breast volume, a moderate-sized saline implant in a submuscular position should give you what you’re looking for.
It is my experience that saline implants will look great but typically feel less natural, especially as time goes by. Saline allows me to correct minor asymmetry of the breasts and place through smaller incision but usually some rippling of the lower lateral breast. I would suggest always placing saline implants under the muscle in attempt to soften the feel and look.
Do Saline Breast Implants Look and Feel Natural?
Saline implants can present as very natural appearing augmented breasts when placed under the muscle but they do not feel as natural as silicone implants. They are a good choice for patients either scared of silicone or for economic reasons.
Saline breast implants, especially when place under the pec muscle, can look and feel as good as silicone implants. With saline implants you gain adjustability and save some cost. If you . If you have little breast tissue,you need to be careful to choose a midest implant so to minimize visible rippling or wrinkling.