Implant Exchange in Same Pocket Sometimes Yields Better Results
Your photo indicates that over the course of aging, gravity, loss of elasticity, pregnancy, weight fluctuations, hormonal changes (pick any that apply!), your own natural breast tissue has fallen off the mound of the implants. However, your nipple position still appears to be at or maybe just slightly below the level of your inframammary fold (which implies a lift is not imperative). Many women use the need for surgical treatment of a ruptured implant as an "excuse" to correct the appearance of the breasts that has occurred over the course of time.
While you have options, I would recommend the following: 1.) remove your ruptured implants via an inframammary fold incision, 2.) perform capsulectomies (it is likely that in the face of gel implant ruptures and 24 year old implants, you have some calcifications of your capsules) to create a "fresh" pocket in the same plane, i.e.submammary, 3.) revise the pockets so they are symmetrical, including lowering the level of the inframmmary fold to help visually correct the sagging appearance (the lower breast falling off the implant) and 4.) replace an appropriate style/size of silicone implants to provide a natural appearance.
The reason I would use an IMF incision is that performing capsulectomies through other incisions is extremely technically difficult and can be traumatic to the local area. The reason I would stay in the same plane is that your natural overlying breast tissue has "stretched' to accommodate the implant over time....if you go below the pectoral muscle, the breast will look like it is falling off the mound of the subpectoral implant, and a lift will surely have to be done to avoid a "double bubble' deformity. The reason I would use silicone is that because the submammary plane is to be used, it will help to prevent the visible appearance of wrinkling that is sure to occur if a saline implant were used beneath your thin tissue. Good Luck!
It sounds like you have already made some important decisions.
The part of the procedure that every one would include is the removal of the old implants and the hard capsules. After this part, there are many ways to go.
If you have considered the issues and risks of staying above the muscle then the new implants could be placed in the same pocket. Do you want to change the size? After the capsules are removed you will have a thinner amount of tissue covering the new implant and you may be able to see ripples from the implant. Do you want to elevate the low nipples and loose hanging breast? This would require a breast lift.
If you choose to put the implants below the muscle you will have a looser appearing and droopier breast. This would prompt most ladies to do a breast lift. When I am faced with a situation like your, which is not rare, I recommend the ladies have the capsules and old implants removed and do a breast lift on the first surgery. After about three months of healing the new implants can be placed under the muscle. During this second procedure some minor revision can be done with the breast lift if needed.
I am not surprised you have heard a lot of different opinions and options. No one option is "the right answer" for you. Discuss the alternatives with your surgeon and this will lead you to the best option for you.
No straight forward answer, only options
What you decide on doing will be determined by what you and your surgeon determine to be the priorities in the surgery and the risks or side effects you are willing to accept. The question of a lift depends on what amount of sagging or shape you are willing to accept. You breast soft tissues have stretcehd and sagged over the implants. If you simply replace them, there will be no change in the sagging. You might be fine with that if the price is more scars around the nipple. If not, you may need to increase the size of the impants or do some sort of lift. What lift and what size implant depends on whether your are more interested in final size, or presence of scars.
Generally speaking, implants under the muscle with your degree of sagging will produce a more sagging look with the same size implant than an implant over the muscle.
I would recommend seeing which surgeon is someone you can work with, explains the reasons why he recommending what he is recommending, listens to your needs, or even forces you to voice your opinion. Your surgical plan should be a collaborative effort. There is no one single kitchen, but you should get the kitchen you want.
Re-do breast implant augmentation above or below muscle?
The decision should be based on your anatomy. Since you have your breast implants above the muscle now and have had them done through an infra-mammary incision at the breast fold, it is reasonable to have them re-done using the same incision and same pocket above the muscle.
At your consultation your board certified plastic surgeon will examine you and discuss your options accordingly.
Many options for breast explantation and re-implantation
Although I am not a big fan of over the muscle silicone implants (as they tend to harden up more over the long term,) it would make your surgery easier. Decide whether or not you mind your nipple position and either have a mini lift at the time or not based on your preference. Definitely get the old implants and the scar capsules removed though.
The decision is so difficult because there are so many good options all of which will result in excellent results. Many of these options have been expressed in previous posts.
From what you have stated, "I don't feel like I need perky breasts and rather keep them over muscle I've been happy with them there". That tells me what I need to know about pocket conversion. You don't need it. If you were having problems with implant distortion or capsular contracture then the location should be changed. I do very few subglandular augmentations (I prefer submuscular) but this would be a situation where I would probably recommend it. If you have very little breast tissue over the implant a lift at the same time may not be wise from the standpoint of the vascularity of the tissue at the time of the lift. It does not look like you need a large lift and I think you would be O.K. Based on the photos alone you would benefit from the lift. The risks, scars, and cost should be weighed against this benefit, the ultimate decision is yours.
As far as incision, I would definitely recommend the previous scar, particularly if you are getting a lift at the same time. Actually, I think that access to the entire capsule for removal would be easier through this direct approach.
It is basically your choice
It appears that you have pinchable breast tissue in the upper breast and you appear to be a candidate for an approch through your existing scar where the old implants and probably the capsule can be removed. Your breasts will be a bit saggier and you may possibly be able to see and feel the implant edges more easily. I also think you would be a good candidate for implant removal with possibly placing the upper part of the implant under the muscle and having a lift. You are a young woman but the choice is ultimately yours.