Is it possible to do an en bloc implant removal, under muscle, and areola reduction? Lift with or without implants?

Hello! Thank you for your question! It is a matter of surgeon preference as well as what is seen during your procedure that will determine whether or not a complete capsulectomy is performed. I have always favored a complete capsulectomy vía en bloc method.  Although a more complex and skilled procedure, I believe it to be the best method, especially given concerns today
If significant capsule formation is seen intraoperatively, a full capsule removal may be warranted with a drain in order to completely remove all of the tissue and allow better adherence of your breast back to its normal anatomic position down on your chest wall. If minimal contracture is seen, it may be possible to leave the capsule, or place cuts within the capsule to allow better adherence.  It is still not completely understood what forms the capsule, but the popular theory would lead most to removing it entirely. It truly is dependent on what is seen with your capsule and the issues that may be causing you to have such a procedure (e.g., contracture from rutptured implant vs pain vs simple pocket adjustment, etc).  But, I completely believe in removal of the entire capsule, en bloc, for several reasons - removal of entire capsule that wasn’t there to begin with, adherence of tissue back to where it started, improved breast contour for revision, and not exposing the body to any implant material or periprosthetic fluids/contents that are within the capsule and in vivo.  These are just a few important that en bloc addresses. Drains should be used to remove the fluid that will inevitably develop in the potential space.  
Without knowing your issues and without an examination, it is difficult to tell you what may be the best thing for you. I favor performing capsulectomies (in an en bloc fashion) in order to create a fresh pocket, reshape the pocket, allow better shape and adherence of the overlying breast. I would discuss your issues with your
plastic surgeon who will assist you in determining the right modality for you. Given the capsule formed from the foreign object and was not there to begin with, as well as some theories of what exactly is a capsule and what causes it to form...I favor complete capsule removal.  I would expect a somewhat similar appearance as if you have not had implants, as your breasts have also aged over the past few years. The decision on whether a lift may be performed depends on how much of a lift is needed and ultimately vascularity to the breast.  Otherwise, consideration as a staged procedure with/out fat grafting may be done then or at same time,  Hope that this helps!  Best wishes!

The technique I recommend is explantation using The Bellesoma Method.  The implants are removed, your breast tissue is reshaped creating upper pole fullness, elevated higher on the chest wall and more medial to increase your cleavage.  Vertical scars are avoided, nipple sensation and the ability to breast feed are maintained, if not injured during your previous surgery.  At the same time or later, fat transfers can be performed if additional volume is desired.  Implants are not lifetime devices and half are removed by 9.5 years.  Fat transfers are permanent and incorporated into the body.Best Wishes,Gary Horndeski, M.D.

As you have mentioned in your post, there are many options available to you. Ultimately, which operation you undergo will depend mainly on your personal goals. Downsizing of breast implants may be the right answer in your case. Keep in mind as you are thinking about your goals that sometimes adjustment of the breast implant pockets (capsule adjustments) and/or breast lifting may be necessary to achieve the outcome you are looking for.   Whether or not the adjustment of the breast implant capsules or breast lifting will be necessary will mainly be dependent on your physical examination; specifically, factors such as the amount of redundant skin, quality of skin elasticity,  and how much you downsize will be important.  
***Although definitive advice would require in-person evaluation (careful physical examination and careful communication of goals are key),  based on the photographs and information in your post, I think that it is very likely that you will benefit from breast lifting at the time of downsizing of breast implants.Generally speaking (in my opinion), unless the breast implant capsules have thickened (and/or are otherwise symptomatic), are associated with the ruptured silicone gel breast implants, or if the patient has concerns about "medical conditions" related to the breast implants, capsulectomy is not universally necessary. For these patients, en bloc removal of breast implants is a good procedure.
On the contrary, capsulectomy can expose patients to additional risks, such as bleeding, size loss, contour irregularities and other serious complications. In other words, any maneuver performed during surgery exposes patients to additional risk (morbidity). For example, attempting to remove very thin capsule densely adherent to the patient's rib cage may expose the patient to significant bleeding and/or entrance into the thoracic cavity.
Generally speaking, the best online advice I can give to ladies who are considering revisionary (downsizing) breast augmentation surgery is:
1. Concentrate on choosing your plastic surgeon carefully. Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you are looking for. ***Ask to see lots of examples of his/her work.
2. Have a full discussion and communication regarding your desired goals with your plastic surgeon. This communication will be critical in determining breast implant size/type/profile will most likely help achieve your goals. 
In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural” or "significant difference” or "full perky C cup" etc means different things to different people and therefore prove unhelpful.
Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup size may also be inaccurate. 
3. Once you feel you have communicated your goals clearly, allow your chosen plastic surgeon to work with you in determining the best plan to achieve your goals.
I hope this helps. Best wishes.