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Breast implants may be placed above or below the (pectoralis) muscle. Although most surgeons insert the implant below the muscle, we recommend above muscle implants for most (but not all)patients.

For one thing, the normal breast is located above the muscle. Therefore, above muscle implants are more natural than below muscle implants.

More importantly, below muscle implants are constantly being squeezed by the muscle whenever the (pectoralis) muscle contracts. This happens when the shoulder bears down with resistance. When below muscle implants move,they usually move either towards the neck or towards the armpits. Eventually, this constant muscle contraction may cause migration of the implants towards the armpits. Implant migration causes an apparent loss of volume. In my experience, below muscle implants are more likely to cause inflammation and pain of the pectoralis muscle because the muscle has to move around the implant every time the shoulder is moved.

The only advantage of below muscle implants is less rippling. Rippling is mainly a problem with above muscle saline implants that are placed in women with very small (A cup) breasts. In these women, there is very little breast tissue to cover the implant, and a below muscle implant may be a better option.  

 

 

Silicone (gel) implants look, feel and "bounce" more naturally than saline (water) implants, but are more expensive. In most cases the differences are not obvious because the normal breast sits above either implant. Thus what is seen and felt in most cases is the normal breast on top of an implant. However, at the outer rim of the breast, the implant is palpable (can be felt). In some cases, saline implants in particular, can ripple.

Rippling is more likely if the saline  implant is filled to capacity, especially if the arms are brought together (see below). Silicone (gel) implants are more viscous (thicker) and are much less likely to ripple. Silicone implants are as safe as saline implants and are typically guaranteed for life. Saline implants are typically guaranteed for 10 years. If an implant leaks during this time, the manufacturer pays for both the implant and the surgery to replace the implant.

One advantage of a saline implant over a silicone implant (besides price), is that a smaller incision will be needed. The bottom line is this. If you want a very good implant and the smallest incision, but do not want to spend a lot of money, a saline implant is the way to go. If you want the most natural implant, regardless of price, then silicone is the best option.

 

 

Implants may be inserted from a variety of locations: Saline and silicone implants may be placed above or below the muscle via the  periareolar, axillary and inframammary incisions. Only saline implants may be inserted via the umbilical incision.

For silicone implants, all things being equal, I prefer the periareolar, inframammary and axillary incisions in that order. Silicone  implants may be placed above or below the muscle from any incision. Silicone implants look best above the muscle and have minimal rippling, even in women with small (A-cup) breasts.

For women who desire saline implants, I prefer the umbilical, periareolar (nipple), axillary and inframammary incisions in that order. Women with small breasts (A cup) who desire saline implants may have less rippling with below muscle saline implants. Women with larger breasts (B cup or higher) look better with above muscle implants. There are mitigating factors that would make me change my incision preference. For example, if nipple repositioning or reduction is needed, then the nipple incision is best. 

 

 

 

 

 

For women who want the most natural implant, the above muscle silicone implant is the way to go, if you don't mind the higher cost and somewhat larger incision of silicone implants.

For women who want a very good implant at a more affordable price and somewhat smaller incision, saline implants via the umbilical approach is the way to go. The umbilical approach is the most cosmetic because it avoids any scarring around the breast. In this approach, a small (5 mm) incision is made at the umbilicus. The implants are tunneled underneath the skin and placed under the breast.

For women who have moderate ptosis (sagging of the nipple below the breast crease) or who need nipple reduction, the periareolar (nipple) incision is best. In this case, a periareolar incision with nipple repositioning or resizing can be done simultaneously.

Women who want large silicone implants may benefit from the axillary incision.

 

 

 

Some patients desire adjustable saline implants. These implants may be adjusted months or even years later. Almost all patients are not symmetrical between their right and left sides because of normal differences between the  breasts and/or  (pectoralis) muscles. Actually, a small normal assymmetry looks more natural. However for some patients, these size differences may be dramatic. In such cases, adjustable implants may be considered.

 

 

 

Then again, some patients like adjustable implants because they can fine-tune their breast size when they're awake, after trying a variety of clothes. Adjusting these implants (larger or smaller) can be performed during a 10 minute office visit. Some professional models, dancers, etc.  like to adjust their implants before a particular event or shoot.

Finally, there are those  patients who try to achieve near-perfect symmetry between their breasts. For those women, adjustable implants is the way to go. However, as is seen below, near perfect breast symmetry may not look as natural as slight breast assymetry.