From Dr. McKee:
The second problem that arises from saline is particularly in very thin women, it’s very hard to disguise the top of the implant in a saline implant… they tend to stay very tall at the top of the breast, which is a dead giveaway that it’s an implant. In an unsupported breast, you should not be able to tell where the top of the implant is, it should be a gradual, natural slope off the top of the chest. I’ve had a lot of men tell me “Oh, I can tell when a woman has implants because you can see the top of the implant.” Well, if a woman has a bra or swimsuit on, all bets are off because a full-breasted woman with all her own breast who is supported in a bra, you will see the top of the breast, it’s not necessarily an implant. But in a thin woman without a lot of subcutaneous fat with a saline implant you can see the top of the implant. Now, a lot of women don’t care about that anymore. I used to think the goal was to make it look so natural that you couldn’t tell it was an implant either by looking or by feeling, but apparently that’s no longer the case with some of the younger patients particularly. I had a patient who was very unhappy- she liked her size, but she was unhappy because nobody could tell that she had implants. So I learned something from her: I have to find out what the patient wants. But MY goal is to make a natural-looking breast that you can’t tell has breast implants.
That relates, to some degree, to the question of the placement of the implant: whether it’s below the breast or below the muscle. If a patient says “I don’t want it under the muscle” and for some reason I have to use a saline implant, in many of those patients, I’ll be forced to put it under the muscle to try to disguise the top of the saline implant, because there’s more padding on it, it put more pressure on it, and it gives it a smoother look. Whereas if you just put a saline implant in a relatively thin woman and you just put it under the breast, you’ll be able to see the top of the implant.
So generally your preference is to put the implant above the muscle?
DEM: my standard operation, barring other considerations, is inframammary incision, in the crease under the breast, smooth, round, silicone, under the breast above the muscle. That’s the most natural place for a breast replacement. God didn’t put breast under your muscle, he put it above your muscle. So I think the most natural place to put a replacement for a breast that God didn’t give you is above your muscle.