Should I move from under to over to address CC? - Risks of more issues

Due to development of CC on right side I am looking to have revision that would move from under to over muscle. My concern is I am a thin build (5'6" 115lbs) and was barely an A cup pre-surgery. I am also concerned about chance of CC recurring. I do like idea of reduced distortion as I am also a gym gal but also concerned about implants being more visible.

Doctor Answers 7

Options for capsular contracture in thin athletic patients

Over muscle implants will be more prone to visible rippling in thin patients. Fortunately the use of an acellular matrix such as Strattice is very effective at preventing recurrence of capsular contracture while also adding support and coverage for the implants. After capsulectomy, coverage will be a significant issue. If you have problems of animation deformity, then I would recommend considering switching to the split muscle plane. This allows muscle coverage of the upper part of the implant, and restores the lower portion of the muscle to its anatomic location so there is no animation and full muscle function. Bottom line is if you go over the muscle and there are problems such as rippling that could have been prevented with Strattice, then you will end up having additional surgery and spending more money in the long run.

Seattle Plastic Surgeon
4.9 out of 5 stars 52 reviews

Moving Breast Implant From Under to Over to Address Capsular Contracture?

Capsular Contracture, once established, can be a difficult problem to correct and your situation unfortunately illustrates the many competing variables that can have an impact on whether your surgery is successful.

Historically, one of primary ways of dealing with capsular contracture was to change pocket location. In the past, this usually meant moving from the sub glandular (over) to the sub pectoral (under) position, because years ago augmentation was most frequently done over the muscle, and capsular contracture rates were quite high. Today we know that the capsular contracture rates for sub glandular implants is high, especially for smooth implants, so most surgeons avoid doing augmentation this way. In your situation, going from sub muscular (under), to sub glandular (over), means that your implant will be moved to the location where capsular contracture is highest. I, like you, would be very concerned with the risk of recurrent CC. 

Some other considerations. Are both implants being relocated to over? If not, then your breasts will not likely look symmetric. Is your surgeon using a new implant? It is recognized that one of major causes of capsular contracture is contamination of the implant with a small number of bacteria when the implant was put in. The bacteria adhere to the implant shell and form a biofilm that protects them your bodies defenses. However, if your body can't kill off the bacteria, it creates a state of chronic inflammation which results in capsular contracture. So you should at least be getting a new implant as well.

It is true that a sub glandular implant (over) will have less of an issue on animation deformity (distortion with muscle flexion), but if your tissues are thin, then you are likely to face the problems of a visible implant or visible rippling - also highly undesirable.

Another approach to managing capsular contracture is the addition of Strattice to the corrective procedure. There is increasing data that indicates that adding Strattice can significantly reduce the rate of recurrent capsular contracture. Also, part of the treatment of your capsular contracture will likely include a capsulectomy which will further thin your already thin tissues. Strattice will provide extra support for the implant, thus minimizing the risk of subsequent malposition, and the Strattice will provide extra coverage of the implant, thus reducing the risk of implant visibility. Strattice has even one more benefit for you. When the Strattice is sutured in place, it is usually sutured to the inferior border of the pectoralis muscle and then is sutured to the chest wall. This creates a sort of hammock that supports the implant, but also serves to minimize the upward motion of your muscle thus minimizing your animation deformity. 

So, my recommendation in your situation would likely be to revise both sides to maintain symmetry, capsulectomy of the effected side, new implant, keep the implant in the sub muscular (under) position, add Strattice for the benefits of minimizing risk of capsular contracture, better support of the implant in thin tissues, reduced risk of visible implant through thin tissues, and minimizing the animation issue from a sub muscular implant. 

The Strattice solution is really the only one that addresses all of your potential problems and will most likely give you a satisfactory long term solution. It is, unfortunately, also an expensive solution because the material is costly and the surgery to position it is time consuming. However, is it not better to invest more in something that has a higher chance of working properly and minimizing other problems. Far too often I see patients who have undergone multiple revisionary procedures to treat capsular contracture, only to have it recur or develop other problems. They have spent more money on the multiple procedures than what it would have cost to do it once with Stattice. When you consider the risks of some the lesser approaches to treating capsular contracture, the Strattice option starts to look awfully attractive. It is not always the preferred solution, but should be in the mix of options. The old approach of simply changing pocket location is no longer the preferred solution.

Braden C. Stridde, MD
Kirkland Plastic Surgeon
4.8 out of 5 stars 52 reviews

Revision Breast Augmentation for Capsular Contracture

Everything in revision breast surgery is, to some extent, a compromise. I almost always do a capsulectomy and place the implant in a different position. Besides, in you, with your arm use in the gym, placing the implants over the muscle is an excellent idea. I would suggest textured implants. They do excellently over the muscle at reducing capsular contraction. I would also recommend making sure your surgeon uses preoperative antibiotics and irrigation of the pocket with antibiotics. There are also other small technical details that can help reduce the risk of another contracture. Make sure your surgeon understands the things that can be done, though it sounds like you are in good hands.

Robert T. Buchanan, MD
Highlands Plastic Surgeon
5.0 out of 5 stars 6 reviews

Submuscular vs. subglandular for Capsular Contracture.

Thank you for your question. There are a number of ways to address capsular contracture; change the pocket, use textured implants or use an acellular dermis. It would be best to go for a consultation with a plastic surgery who could examine you and determine which combinationof treatments might be right of you and your body type.

Lisa M. DiFrancesco, MD
Atlanta Plastic Surgeon
4.8 out of 5 stars 34 reviews

Site Change and Capsular Contracture

A site change from under the muscle to about the muscle may not be beneficial in your case since you are very thin. We may do more harm. I would recommend changing to a text implant and adding and acellular dermal matrix(ALLODERM®, STRATTICE®, etc). 

Earl Stephenson, Jr, MD, DDS, FACS

Operative treatment of capsular contracture in the breast

Generally speaking, when capsular contracture has developed removal of the capsule is indicated and there are a few options for positioning the implant. Certainly changing the plane would be a benefit, however the trend currently is to perform what is called a neopectoral pocket where a new pocket in the same plane is made while still keeping the implant under the muscle where it is more concealed. In addition, use of a biologic pig skin type product in such cases has shown some promising results at decreasing the risk of recurrent capsular contracture.  It would be in your best interest to consult with a board certified plastic surgeon that has experience in complicated revisionary cosmetic breast surgery for an examination and thorough recommendations!

Megan Jack, MD
Boca Raton Plastic Surgeon
5.0 out of 5 stars 15 reviews

Breast augmentation

I agree. above the muscle is too risky for someone  like you. sooner or later you will have palpability and perhaps even visability. stay under the muscle, do a total capsullectomy use steriods and some of the newer meds that prevent capsular contracture 

Joseph A. Russo, MD
Newton Plastic Surgeon
4.4 out of 5 stars 27 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.