First off, there is no definitively correct answer here. Fixing capsular contrature can be very difficult, which you have discovered. Also, repeating the same operation when it didn't work the first time doesn't make sense.
Traditionally the approach to treating capsular contracture has involved removing the old implant, and often the capsule, and then putting a new implant back in a different position(i.e. from under the muscle to over the muscle). However, implants on top of the muscle overall have a higher of capsular contracture, although textured implants tend to reduce this risk. On the other hand, you need to enough enough tissue coverage for an implant on top of the muscle and if your tissues are thinned, the result will not look good.
Alternatively, you could use Alloderm or Strattice in conjunction with removal of your old implants and capsulectomy. The addition of alloplastic material (Alloderm/Strattice) does appear to reduce the risk of recurrent capsular, and these materials provide better support of the implant and help thicken tissues which have been thinned by multiple capsulectomies. Stattice is less expensive and stronger, providing better implant support, so it would be my preferred choice.
Plastic surgeons note know what causes capsular contracture. There is been a number of strategies none of which guarantees that it will not recur. Uses ADM has its problems and should be performed only by someone who does this regularly. It's also expensive.
Capsular contracture is the Achilles Heel of breast augmentation. Treating recurrent capsular contracture is even more difficult for patient and surgeon alike. I assume that you have chosed an experienced and skilled plastic surgeon and had a through discussion with him/her. The "best" option is really impossible to know particularly since no one online has your complete relevant history nor done the physical examination - key to proper diagnosis and therefore key to proper treatment. What type of implants did you have previously, what pocket approaches were used, any sign of infection, was a capsulectomy performed, was it total or anterior, have you previusly had a pocket change, did you have a hematoma or seroma, what are the soft tissues of your upper breast like, etc.
Speaking in generalities, the dual plane offers some protection against capsular contracture; however, when there has been a contracture in that plane the data is less clear. Textured devices offer protection against capsular contracture, acellular dermal matrix offers protection against contracture. You may wish to consider prolonged post--operative antibiotics (not studied in the breast augmentation patients but in breast reconstruction patients).
Discuss with your surgeon and good luck
Unfortunately, not matter what is done you may still can end up with CC. A couple things have been possibly shown to decrease the recurrence. 1. Tissue scaffolding(strattice or alloderm). 2. Textured implant and 3. Singular/Accolate started before surgery and continuing for a couple months after.
I hope this helps
Ritu Chopra MD
The correct answer is placing a textured implant over the muscle would be appropriate. You might want to give consideration to removal of both of your implants and no additional implants placed.
Earl Stephenson, Jr MD, DDS, FACS
Strattice is the Acellular Dermal Matrix (ADM) most commonly used for capsular contracture, but Alloderm would also work. Strattice is my "go-to" option for recurrent contractures and it has been extremely effective. With several capsulectomy procedures, your tissues will be thinned and there will be less coverage and support for the implants; Strattice will also add coverage and improve the look, while textured over muscle implants may be more likely to look unnatural.
It is difficult to predict what would be best because there are many options with no perfect solution. The two choices I might consider would be to perform a capsulectomy and let things heal and return in a few months to start over, or use strattice and a new implant.
Anytime you have repeated capsular contracture, it can become a very difficult and frustrating thing to deal with. In your case, since all three prior attempts were sub muscular, I may change you to subglandular with an anatomically shaped/ form stable silicone gel device. This would decrease the chance of palpability issues when going above the muscle, while avoiding the old pocket that seems to be the issue. If your tissues are too thin for sub glandular, then remaining underneath the muscle would require the use of an ADM ( acellular dermal matrix such as Alloderm or Strattice) to take the place of he lower pocket support. The rates of recurrent contracture when using such material appears to be lower, but the data is not very exhaustive. I hope this helps.
I am sorry to hear about the complications you have experienced. In my practice, I would likely offer you capsulectomy, exchange of breast implant, and the use of acellular dermal matrix. You may find the attached link, demonstrating similar cases, helpful to you. I would be concerned about a variety of additional problems that may arise from breast implants placed in the sub glandular position. Best wishes for a successful outcome.