Breast revision: what would be best in my case, over or under the muscle? (Photo)

I have seen several doctors and have had different recommendations to improve the look of my breasts. A lift, removal of capsules and implants with new placement of implants both over and under the muscle and of varying sizes. My current implants are silicone, over the muscle, 360cc. The contracture in the left breast is painful and the right breast has no shape left so it's possible that it has ruptured. I'm very confused as to what I should do. I was happy with the look of these 15 years ago.

Doctor Answers 9

Breast revision...over or under?

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Thank you for your photographs and questions.  You do need a face-to-face consultation with a board-certified plastic surgeon to review all of the details and options available to you.  However, with rare exception my recommendation would be to perform capsulectomies and explantation of your 15-year-old implants and replacement with new round smooth cohesive silicone gel implants in a partial subpectoral position.  The rare exception would be a patient who was soft and happy with her result for most of the 15 years until hardening developed at the very end.  This patient if unwilling to undergo a slightly longer recovery required for subpectoral exchange might be a candidate for return to the same pocket but in my opinion this would be rarely recommended.  A much more natural result and a greater chance of a soft unencapsulated result over the long-term would be expected by placement in a partial subpectoral position in my humble opinion.  The video link above will explain further.  Best of luck in making your choices,

Jon A Perlman M.D., FACS
Diplomate, American Board of Plastic Surgery
Member, American Society for Aesthetic Plastic Surgery (ASAPS)
ABC-TV Extreme Makeover Surgeon
Beverly Hills, California

Beverly Hills Plastic Surgeon
5.0 out of 5 stars 34 reviews

Over or once?

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Submuscular placement may be more uncomfortable the first few days following surgery. The possible benefits of submuscular placement are that it may result in less palpable implants, less capsular contracture, and it will make it easier to image the breast with mammography. The appearance may be more “natural” for patients who are very thin. Subglandular placement may make your surgery andrecovery shorter and you may have less discomfort. This placement may provide a slight “lift”. Subglandular placement may result in more palpable implants, more capsular contracture and more difficult imaging of the breast with mammography. This placement is often recommended for those patients with sagging, but do not want a breast lift (mastopexy) and for tubular breast deformity

Breast revision...over or under?

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Without an exam no one is going to be able to give you a complete answer. Nationwide the vast majority of surgeons prefer implants under the muscle as the CC rate is dramatically reduced so in cases like yours you will find 100% of surgeons recommending new implants and over 75% recommending under the muscle.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 29 reviews

Advice on revision surgery for BBA

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You must be concerned about this and that is understandable.

It is okay to be confused, and many patients find themselves in similar situations many years after their original surgery.

Although there are many options you can exercise to get aesthetic looking breasts like you had previously, there are some things that need to be done.

If you have capsular contracture in the left and right breasts such that they either look abnormal and/or are painful, then the capsule surrounding the implants has to be removed as the problem can get worse. If there is nothing wrong with the explanted implants (i.e., there hasn’t been a silent rupture), then they can be implanted back in.

You can either have them implanted over or under the muscle.

With over the muscle, you will preserve your pectoral muscle functionality, there will less trauma to your chest muscles, your implants will provide direct pressure to the breast tissue to enhance augmentation, but you may experience higher risk of breast tissue wasting and capsular contracture. There may also be higher risk of implant visibility and palpability, especially if in the last 15 years, your breast tissue has atrophied.

With under the muscle, you may find a more natural look with a slope in the upper pole and a curvature in the lower pole, there will be less risk of implant visibility/palpability in the upper and inner sides of the breasts. It provides less interference with mammography and breast imaging. It also brings lower rates of capsular contracture while employing the no-touch technique. However, under the muscle may cause animation deformity.

An in-person consultation will provide you with more information, but the implant pocket decision truly depends on the amount of soft-tissue coverage, the volume of the implant, and the filler of the implant (i.e., silicone or saline). If there is sufficient soft-tissue coverage and the implant is adequately sized, then there will be no implant palpability and visibility.

Your breast does not seem as if it is sagging, but you may want to increase the implant size in case you have lost some breast tissue in the last 15 years. If there is a lot of loose skin after removal of the capsules and reinsertion of the older implants, then a breast lift may be needed. 

You should choose a surgeon you trust, who gives value to safety, and who does not rush you. They shouldn’t necessarily agree to everything you say either because you wouldn’t know what is best for you, so it the job of us surgeons to guide to make decision that will minimize complications and allow you to have beautiful breasts. So you must verify their skills, education, and certification. Ask about your surgeon’s experience about the procedure you want and ask to review photographic examples of your surgeon’s work. Check to see if the aesthetic ideal is consistent with what you are hoping to achieve. Make sure the before and after images have the same perspective, the same lighting.  Read the surgeon’s reviews for the procedure you want.

Hope this helps.

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 521 reviews

Capsular contracture and breast revision

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I would like to know a few other bits of information.  Are the silicone implants smooth walled?  Were you happy with the shape prior to these events occurring?  Are you happy with the volume and size of your breasts?  Have you had a mammogram, ultrasound, or MRI?

Although one photograph doesn't give us the complete picture and an examination and discussion of the options by a ASPS board certified plastic surgeon is needed to completely assess your situation, a few generalizations may be made.  Firstly, since you've developed a capsular contracture in the left breast, changing the situation to reduce this occurring in the future is indicated.  As such, your plastic surgeon may recommend a change in position to subpectoral (are the implants subglandular now?) and change to a textured implant (if your present implants are smooth walled) or a different textured implant.  Removal of the implant capsule may be indicated, especially if it is calcified.  The factors of what you liked in your initial postoperative result - and that which you didn't - should be discussed before the recommendation of a new implant. Then, a breast lift may also be recommended with the trade-off of having scars being thoroughly discussed.  A caring plastic surgeon will spend the necessary time to help you decide what is best.  Best of luck to you!

Breast revision...over or under?

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Most would tend to suggest to you a new submuscular pocket for a smoother and softer breast with less visibility of the implant. The implant choices depend on the look and breast feel you think is best for you

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Best Advice

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Thank you for the question and because there are several options open to you that is why you are getting conflicting opinions.  The best advice would be to see experts in the field in your area with a lot of experience in revisions, look at photos of similar patients with your problem, compare fees and find your surgeon.

Dr. Corbin

Frederic H. Corbin, MD
Los Angeles Plastic Surgeon
4.9 out of 5 stars 65 reviews


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Thank you for your question & photo. Your Plastic Surgeon will want to remove all scar tissue, correct/reinforce the implant pocket and place new implants. If you have very thin breast tissue/upper breast pole then likely part-way under the muscle would be appropriate but your surgeon may recommend a fuller, cohesive gel implant to adequately fill out breast volume and reduce the risk of a sagging look. In person exams to determine approach are best because a picture alone doesn't allow us to properly evaluate. I recommend that you ask questions in person with your Plastic Surgeon and let them explain the pros and cons for each approach before you decide.

All the best

Planning correction of capsular contracture around gel implants over the muscle

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Thank you for asking about your breast implant revision.

  • I am sorry you are going through this.
  • Capsular contractures occur at a rate of 1% a year and so they can appear any time.
  • There isn't a right or wrong approach because the problem is complex.
  • However I would probably remove the implants, remove the capsules, place new implants under the muscle and cover the implants with some kind of mesh or surgical tissue to support the implants and reduce the risk of future contractures.
  • If you have the older gel implants (as you may since they were done 15 years ago) and there is a rupture, it might be necessary to stage the operation.
  • So ask your plastic surgeon to do an ultrasound in advance of surgery so you and s/he can plan this procedure well in advance.

Always consult a Board Certified Plastic Surgeon.  Best wishes. Elizabeth Morgan MD PHD FACS

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.