I had breast augmentation about 6 years ago and have capsular contraction in my left breast with noticable implant outline. The implants were placed above the muscle. I have just had 2 consultations with different surgeons about replacing both implants - one says to definitely go under the muscle this time, the other says to put the new implant in the same pocket above the muscle or it will look terrible (something about banding?). I am very confused?
What Pocket to Place New Implant - Existing or New?
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Revision implant surgery for capsular contracture
For a treatment plan, I would recommend a total capsulectomy and implant removal and placement of a new implant in a new pocket.. In your case, I would do whats called a site change surgery and transition the implant from the subglandular position to the submuscle or dual plane position. Why? I'd like to place the implant in a new vrigin pocket - a pocket with no history of scar tissue formation. I would also place some sutures to obliterate the empty subglandular space (old implant pocket). Hope this helps.
Subglandular implant with capsular contracture: placing implant into new pocket
IF you see 3 surgeons, you will likley have 3 different opinions. and so I will toss my recommendations in here for further confusion. I have been realatively pleased with the use of a neo-pecotral pocket. This means that the implant is removed and the capsule is preserved but the implant is placed into a new pocket beneath the existng capsulel. Rates of recurrent capsules have been low. This avoid the possiblity of detaching and having to secure the released pectoralis major muscle when transitioning to a submuscular pocket.
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Where do we put the implant?
As others have said, traditionally a new pocket is created to treat capsular contracture. If it was below the muscle, we put it above; If it was above the muscle, we put it below. This is old dictum based on good experience: Capsular contracture tends to come back if the pocket the implant was in is not removed. This is probably because there is a bacterial component to most contractures that requires erradication to prevent recurrance.
Changing pockets in 2010 is not necessary therefore if the pocket is treated appropriately; either total removal or obliteration by allowing the pocket to collapse on itself and sewing it closed. Either way though, this leaves the implant very close to the surface of your breast if your implant is above the muscle, and this could be a big problem if you don't have a lot of your own natural breast tissue, and can lead to palpability of the implant or even visible rippling of the implant through your skin.
In general, implants do better below the muscle and have a lower risk of capsular contracture. There are other potential issues associated with switching pockets from above to below the muscle, and these need to be carefully examined by your surgeon to determine that additional procedures are not warrented, like a breast lift, or a change in implant size, or both.
You should be sure that your doctor is skilled at revision breast implant surgery as this is important to the success of your outcome. Best of luck to you!
Breast Implant ReDo- Which Pocket after Capsular Contracture?
The standard textbook advice for capsular contracture is capsulectomy followed by site change and device exchange. That means taking out the old implant, as well as the surrounding scar, closing the pocket, followed by making an entirely new pocket opposite to the original (under the muscle if the original was over the muscle) and using a new implant.
That said, there are many variations and options available. For example, some surgeons create a new pocket either above or below the original in the same location, but don't remove the original pocket. Instead, they obliterate the old pocket with 'quilting sutures' and then create a new pocket using the old capsule as extra cover over the new implant. This is a complex area where several key decisions need to be made. What is best for you is not possible to say without a proper consultation.
Implant Site Change and Capsular Contracture
Unfortunately, capsular contracture is a real complication associated with breast augmentation, and I tend to see this more frequently in implants placed above the muscle. Also, implant visibility is clearly more common in this setting. Two problems you seem to be suffering from. The solution, although not simple, would be to remove the implant and capsule and place the new implants beneath the muscle - this should help in both of the above scenarios. However, the muscle can exert some force on the implant and create an area of depression or banding (assuming that this is what your surgeon was referring to) but this is unlikely and uncommon. You do currently have two problems that exist and the visibility will certainly persist if the site is left unchanged (or you go to a significantly smaller implant). The chances of the capsule reforming are less, but studies have shown this to be less frequent in the sub-muscular position.
Best of luck,
Vincent Marin, MD, FACS
San Diego Plastic Surgeon
Capsular contracture and implant pocket
The most prudent option would be to place silicone breast implants in the submuscular plane to minimize recurrent advancement of capsular contracture and rippling.
A new implant should be placed in a new pocket in most cases
The vast majority of time when removing prosthesis for capsular contracture in the subglandular position, new prosthesis should be placed in a submuscular one. If there is a question of banding, then a partial capsulectomy can be performed in that area. What is of greater concern is on switching from a subglandular to a submuscular plane there may be some redundant tissue that needs to be addressed so that you do not have the appearance of glandular ptosis. What can be difficult are those patients with long standing old silicone prosthesis that have leaked, resulting in capsules that feel like cracked eggs and are calcified. In those cases they generally require near complete capsulectomies so there is no visible or palpable residual capsule. In other words if it is a straight forward switch, a submuscular plane would be appropriate.
Pocket location after capsular contraction
If you have them in the subglandular pocket, first you would like to remove as much of the capsule as possible. In addition, placing them in a submuscular( biplanar) approach may offer better superior coverage but it is not mandatory to do so.
Revision breast augmentation can remain above the muscle.
As you can see, this is as much an art as a science. Of course it depends on the individual anatomy. Creating a new pocket under the muscle can create a new deformity and so should be approached cautiously.
There are studies that show that using Alloderm in revisions (over the muscle) helps prevent recurrence of capsular contracture.
Over the muscle and under the muscle can both work well. The most important thing is the skill of the surgeon.
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