Smooth Round Silicone over the Muscle. My Friends Are Against It And Say To Go Over?

Went to my 1st consult with a doctor that 6/10 friends went for their surgeries I'm almost 36B now, want to be about a 36D. The doctor took all my measurements said I have awesome breast tissue and a lot of it and he recommended 500cc silicone smooth round (he said he NEVER uses textured implants) over the muscle.My friends are freaking me out because most have saline under the muscle, said it is not a good idea, but he is the doctor! my other friend said only textured should be over. Help!!

Doctor Answers 14

Breat augmentation: saline vs. silicone and over or under the muscle.

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New gel implants are waranteed for life.  They are soft and natural and are very well tolerated under the breast (over the muscle).  This is particularly true for implants that are smooth.


The problems that arise when implants are placed under the muscle is that the muscle separates the implant from your own breast tissue.  Over time your breast tissue will droop.  If the muscle holds the implant in place the implant will not droop and there will be a separation of components. This leads to a "double bubble" contour.


I am in favor of an over the muscle approach for most people. There is no one right answer.  Make sure you understand all the pluses and minuses before you make a decision, but in my experience the over the muscle approach offers the most natural results that will stand the test of time.

Your friends are (mostly) right, but for the wrong reason!

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First of all, you should take the advice of non-plastic surgeons (friends) with a truckload of salt, and the advice of plastic surgeons who have never examined you or spoken with you directly with at least a grain of salt. Your friends may have your best interests at heart (they may also be unable to filter jealousy or could be "frenemies"), but even the purest of intentions by your friends is without the training and experience of any ABPS-certified plastic surgeon. Also, individual experiences (anecdotal events) are neither scientifically relevant, nor indicative of "the right choice."

Plastic surgeons have the benefit of medical school, surgery residency, plastic surgical fellowship training, written examination, oral examination, American Board of Plastic Surgery certification, and years (variable depending on surgeon) of experience with numerous (extremely variable depending on type of practice, years of practice, and cosmetic, reconstructive, or mixed practice) breast augmentation patients. Some plastic surgeons are more scientific-minded than others, and even well-trained and seasoned plastic surgeons may rely on their personal experiences more than scientific studies in their practices. Frankly, I like both, because science is devoid of emotion and does not rely on anecdote. However, science may not explore every variable and cannot account for the human experience that can incorporate the nuances of detail that a busy breast augmentation practice includes.

So with that lengthy prelude out of the way, I would consider that your own tissue does indeed provide adequate coverage for implants place above the muscle, likely why your surgeon chose this rather than the below-the-muscle position utilized for your girlfriends. Perhaps they chose saline over silicone (not an error, but I and a majority of plastic surgeons have found that there is less rippling with silicone, a more natural "feel", and no chance of deflation with silicone).  Silicone is still utilized by a majority of plastic surgeons world-wide for elective breast augmentation. The latest generation of silicone gel implants are cohesive and cannot leak (even if they were somehow ruptured--say,if you were in a car wreck). Perhaps your friends had too little breast tissue of their own, requiring submuscular placement--saline implants are usually placed below the muscle to diminish the visible rippling or "edge" feel, can leak and deflate, and usually feel less natural.

Going below the muscle taught most of us that capsular contracture was less common in this location (at least for those of us who are older and saw lots of years of high CC rates) because of the decreased contact with breast ductal bacteria that happened above the muscle--where the exposed breast ducts could "bathe" the implant surface with bacteria. This is why, even when the FDA re-allowed the use of silicone gel implants (2006) for cosmetic patients, most plastic surgeons still placed silicone gel implants below the muscle. Less capsular contracture is a big deal, especially if you are unfortunate enough to have this happen.

So, regardless or type (silicone or saline) implant you and your surgeon choose, going above the muscle may be OK because of your own tissue coverage, but NOT OK (IMHO) because of the increased risk of CC, even with antiseptic or Betadine irrigation. Silicone textured implants were designed to reduce the incidence of CC with above-the-muscle implants (before the FDA restrictions of 1991), and depending on the age of your plastic surgeon, may be something he is not familiar with. More recently we have the "gummy bear" form-stable McGhan 410 investigative cohesive silicone textured implants. I agree that textured implants have no place below the muscle, since they cannot move and their bacteria-isolating and collagen vector force-disrupting effects are not needed (as they were above the muscle). If your surgeon "NEVER" uses textured implants, that is unfortunate, becuase there are a few situations where years of experience with thousands of patients may make this not only a reasonable choice, but a "best" choice. I RARELY use textured implants, but would certainly do so in select cases if I were contemplating an above-the-muscle augmentation or revision! So at least that friend is correct about this specific recommendation.

I think your surgeon is choosing the right type (silicone smooth) and the right size (500cc = about two cup size increase) for you, but is choosing above the muscle because you have adequate tissue coverage and this will (probably) work out just fine and with a great result. He is avoiding below the muscle concerns (activation distortion, sometimes more pain or bleeding risk--though this is more surgeon and technique-related, and slightly less ability to deal with breast droop or sag), but balancing this are the increased risks of capsular contracture (low with triple antibiotic or Betadine irrigation, but still higher than below the muscle) and a slightly less natural slope below the collar bone (better with below the muscle placement.

So, as other of my colleagues have said, there is no RIGHT or WRONG, just a selection of choices based on science, experience, and your own anatomy and preferences. DO NOT rely on friends as much as your plastic surgeon. I would recommend asking him for a discussion of above or below the muscle, what technique your surgeon uses for each (blunt dissection vs. careful cautery control of bleeders), use of Keller funnel (no-touch technique) or not, and whether or not he is comfortable with your choosing below the muscle. If not, get a couple of more consultations with ABPS-certified plastic surgeons with years of experience in cosmetic breast surgery for additional opinions. Your own plastic surgeon seems to be (mostly) on the right track. Your friends are (mostly) right also.

I would recommend 500cc silicone gel implants below the muscle, choosing the profile based on your breast base width (pocket diameter). For more imofrmation click on the link below. Best wishes!

In Front vs. Behind the Muscle

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You state you are a 36 B and desire to be a D.  This would require approximately 400 cc implant.  So certainly, a 500 cc implant would achieve that plus more.  Silicone implants feel more natural then saline implants and ALL implants feel more natural placed behind the pectoral major muscle rather than in front of it.  According to you description, you believe you have good breast tissue.  I recommend you choose the minimal size implant, 400 cc silicone retro-pectoral, to provide better long term support.  Bigger implants weigh more and will descend sooner.  Without any photographs, I cannot tell your shape but it is possible that you may benefit from breast lift.

Best of Luck,

Gary Horndeski, M.D.

What To Do?

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The other physicians that have responded have outlined the issues that you should consider quite well.  Give these factors your consideration and, if you feel it would be helpful, make an appointment to speak with your surgeon in the office again prior to your surgery date.  Discuss concerns about capsular contracture, mammography, implant palpability and overall appearance of subglandular vs. submuscular implants.  There is no absolutely right way to do an augmentation but you must be comfortable with your decision before proceeding and have confidence in your doctor.  Good luck.

Breast implants

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 I prefer smooth round saline implants placed below the muscle using a one inch arm pit incision and an endoscope. The number one procedure world wide is a breast fold incision and silicone implants placed above the muscle. The bottom line is every doctor has a technique they prefer and you need to be comfortable with the doctor and their short and long term results. Please see a board certified plastic surgeon to help educate you on the choices and good luck!

Above vs. Below the muscle

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You will need to understand your surgeon's thinking before making an informed decision. Most patients have implants placed in the submuscular position. However, above the muscle positioing does provide the benefits of less pain during recovery and some believe a more natural looking result as the implant is behind only the tissue itself. Gel implants feel more natural and you may have indicated that is a primary objective. If you are unsure of the surgeon's thinking, request another consultation. If you are unsure if you have the right surgeon for you then consult with 2 - 3 other experienced and expert board certified plastic surgeons.

Above Versus Below the Muscle

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You bring up two common sources of confusion with regard to breast augmentation - saline versus silicone and above versus below the pectoral muscle.  There is even disagreement between highly skilled and trained plastic surgeons about which is the best approach.  My personal preference is to place implants below the pectoral muscle as I believe it lessens the risk of visible rippling in the upper and upper-medial aspects of the chest.  I believe it also adds value to being able to get a better mammogram image.  Silicone versus saline is primarily up to the patient, although the vast majority of my augmentation patients opt for silicone implants.

Brian Howard, MD (retired)
Alpharetta Plastic Surgeon

Implants and pocket position

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If you do not have a lot of tissue, than under the muscle is probably better, but it is not for everyone.  There are many different alternatives.

Over vs Under the Muscle

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As you are well aware implantable may be placed above or below the muscle.The augmentation result has a different look when implants are placed above as opposed to below the muscle. I show patients results of augmentation with the implants placed above and below the muscle and ultimately the patient decides which look she likes best. Of much greater importance if you are unsure of which direction to go revisit the surgeon and if you are not comfortable with the answers seek a second opinion.

Breast Implants under or over the muscle?

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Dear Baton Rouge,

As the saying goes, there are many ways to skin a cat, or augment a breast!  If your plastic surgeon is board certified by the American Board of Plastic Surgeons and has good long term results with your particular scenario, that is, a large, smooth implant placed above the muscle with good thick breast tissue, then you can expect a good result.  Your friends are speaking in generalities and are correct in saying that in general, fewer long term adverse events occur in patients with implants placed under the muscle and in patients with textured rather than smooth implants placed above the muscle.  Good luck!

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.