Implant Exchange on Old Implants - Keep on Top of Muscle or Move Under?

I've had 450cc saline textured implants on top of the muscle for 16 yrs. I've had 3 more children since that time, & they are too big and saggy now. I have consulted 2 surgeons. 1 is willing to put them under the muscle, claiming that the breast lift will keep them in the new pocket. The other insists I should keep them on top due to built up scar tissue & the possibility of them moving from under the muscle to the old pocket on top. I had planned to go under, but now I don't know what to do!

Doctor Answers 11

Placement of New Implants

I agree that an exam or photo would be helpful; however, if you have 3 children since your initial augmentation it is likely that you have lost a significant amount of upper pole breast tissue.  This would increase the argument for moving your new implants to a submuscular location.  I also have never had implants migrate from a submuscular to a subglandular position.

Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Submuscular implant exchange

More often than not, I would do a submuscular exchange because the implants will look better and stay higher than above the muscle. I have never had a patient slip from under to over the muscle and I close off the pocket connection so that can't happen.  The only time I stay above the muscle is if you have zero capsular contracture and don't want the extra recovery of the submuscular pocket creation.

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
4.8 out of 5 stars 67 reviews

Reaugmentation mastopexy and pocket selection.

With larger implants and sagging breast tissue, it is advisable to switch the pocket from the subglandular position to the submuscular position. This allows for improved camouflage of the implants and improved cosmesis of the breasts. With the addition of a mastopexy to correct the shape of the breasts, the implants are very unlikely to flip to the subglandular pocket.

David Bogue, MD
Boca Raton Plastic Surgeon
5.0 out of 5 stars 25 reviews

Exchange implants and pocket

To determine which pocket to place them in really depends upon your anatomy and preference.  In  most cases, I place them under the muscle because it provides more soft tissue coverage in the upper pole.  An exam would be key.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Implant Exchange on Old Implants - Keep on Top of Muscle or Move Under?

Read Drs Rand and Aldea's posts a few times, they are offering you the correct advise. Go under the muscle. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.6 out of 5 stars 174 reviews

Implant Exchange on Old Implants - Keep on Top of Muscle or Move Under?

I agree with Dr. Rand. There are few benefits for putting smaller implants in the same pocket and a lot more potential disadvantages. For an augmented breast to look great, the pocket must be custom dissected for the implant. Your present pockets would be too large for the new, smaller implants resulting in a poor cosmetic result. In addition, we know from new research on implant infection and biofilms that if your implant pocket is not already contaminated the operation may result in such bacterial seeding with a higher potential rate of scarring around the implants (Contracture).

A submuscular pocket allows a fresh start with the new implants. It would afford better implant coverage and a much better chance for a good long term result.

Dr. Peter A Aldea

Peter A. Aldea, MD
Memphis Plastic Surgeon
4.9 out of 5 stars 109 reviews

Implant Exchange on Old Implants - Keep on Top of Muscle or Move Under

There are some studies that report a lesser incidence of firm #capsules with #placement behind the pectoralis muscle. If you developed firm capsules and your implants were submammary (behind the breast tissue) then conversion to a submuscular position should be considered. This placement is particularly better for the very thin patient who has little breast or fat in the upper part of their chest. In most circumstances, those patients with ptosis (#sagging) require placement above the muscle in a #submammary position or under the muscle combined with a #mastopexy (breast lift) for contour purposes. The best method and #technique for your #procedures will be discussed in greater length during your one-on-one consultation with a board-certified plastic surgeon.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 110 reviews

Replacement of Breast Implants to Submuscular Position

Thank you for the question.

Given your description replacing implants in the sub muscle position is the best way to go in my opinion.  This may or may not be possible depending on your specific situation.

Generally, it is possible to replace implants under the pectoralis muscle (dual plane).  However, the major issue of concern is the overlying breast tissue and skin and whether further surgery will be necessary to achieve the aesthetic  results desired.  For example, some patients who have implants replaced into the sub pectoral space may benefit from breast lifting to achieve the desired goals.

This type of surgery does require some level of experience. It would behoove you to seek consultation with well experienced board-certified plastic surgeons well-versed in revisionary breast surgery.

I hope this helps.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,498 reviews

Change from above the muscle to under the muscle?

You have textured saline implants above the muscle. You do not mention that you have visible rippling of hte implant, despite the fact that these implants in this position has the higest risk of visible rippling.  It sounds like you are wanting smaller implants and that you need a lift.  If your implants are soft without capsular contracture, and you have thick enough tissue that you are not seeing visible rippling even with textured saline implants ablove the muscle, then it may not be that essential to place your new implants to under the muscle, especially if you are changing to silicone gel implants.  On the other hand, if you do have a prominent upper edge and some visible rippling or a capsular contracture, these are all good reasons to change pocket position to subpectoral.  The only disadvantage of the new subpectoral pockets is more discomfort during the post-op recovery from releasing the muscle, and some distortion of the breast that occurs when you contract your muscle, which is only visible when your clothes are off.  These are a small price to pay for better tissue coverage IF that is needed.  I have never had an implant move from a new subpectoral back to the old subglandular pocket, as I close this old pocket off, so that should not affect your decision. 

Robert M. Grenley, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 87 reviews

Implant Exchange and Mastopexy - Breast Lift

Without pre-op pictures or examining you in person, it is hard to give you specific advice as there is not a universal answer for all patients.  However, if you are going to keep the same implants and there is enough tissue coverage, then I would leave them where they are.  However, I think you will get a better result from removing your current implants, placing silicone gel implants under the muscle and then performing the mastopexy.  While there would be added cost for replacing the implants instead of using the old one, I would really recommend making that kind of investment.


Good Luck.

David Shafer, MD
New York Plastic Surgeon
4.9 out of 5 stars 77 reviews

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.