Whats Best, to Prevent Capsular Contraction. over or Under Muscle?

I'm 26, 110 pounds with a 500cc silicone under the muscle. I haside. Going on my 2nd surgery. Dr recommends a 600 cc saline if I want too keep the same size. He stated after removing the capsule..I would have too go bigger.now he wants too place it over the muscle!.not sure I just want too prevent the capsule from forming again. Just want a second opinion?

Doctor Answers 15

There are several things wrong with this scenario!

Since you are asking about a second operation and capsular contracture (CC) recurrence, I will assume you have developed CC in one or both breasts now, and that per your description, your surgeon is planning capsulectomy. So far, so good.

But going from silicone to saline is an error, IMHO. Present-generation cohesive silicone gel implants have no higher risk for capsular contracture than present saline-filled silicone elastomer shell implants. Even if your CC has developed after the use of older (non-cohesive) silicone gel implants (doubtful since you are 26, and the silicone implants in use when you had your first surgery are almost certainly the newest-generation cohesive gel implants), you should have new silicone gel implants placed. Not saline, which can leak (requiring re-operation irrespective of CC recurrence or not), and which are less natural in feel and are much more likely to show or feel rippling.

Solving your CC is the answer to returning to softness, not geting "softer" saline implants!

As to size, complete capsulectomy removes about 30-60 grams of tissue in most cases, so going (slightly) larger to accommodate this is reasonable, but 100cc seems excessive, especially if you want to remain the same size, and assuming your surgeon is not removing a lot of your normal tissue along with the tight scar capsule. Careful surgery keeps normal tissue removal to a minimum while completely removing the abnormally-tightened capsule tissue.

Putting your new implants into a "fresh" tissue plane is not a bad idea, but going from the optimal submuscular position (fewer bacteria with less likelihood of biofilm-induced CC) to a less-ideal submammary plane (where there are lots of exposed breast ducts chock-full of bacteria that increase the risk of CC, regardless of antibiotic or Betadine irrigation) is NOT a good idea. Usually, when there is CC above the muscle (submammary), consideration is given to going below the muscle where there is a better avoidance of those biofilm-inducing bacteria. But then you still have to heal the "old" pocket while still having the "potential" for new problems with the "new" pocket.

When CC develops below the muscle as it has in you, bacteria could still be a potential causative factor, but bleeding may have been a bigger one. (Were you bruised extensively after your initial breast augmentation surgery?) Usually, when CC develops in a submuscular augmentation patient, we remove the capsule as completely as possible, irrigate the precisely-hemostatic pocket with Adams triple antibiotic solution or dilute Betadine to severely-reduce biofilm-inducing bacteria, and put the new cohesive gel implants in the same still-submuscular pocket. While recurrent CC is indeed still possible, this approach usually yields the highest likelihoold of success, particularly if coupled with leukotriene-inhibitor therapy (Accolate or Singulair) and Vitamin E orally for 3 months post-op.

I think you're wise to seek additional opinions, but should do so locally, where ABPS-certified plastic surgeons experienced in breast surgery can examine you and recommend their own surgical plan to definitively-solving your problem. You may find that the approach presently being suggested is not in the majority. SInce even years of experience and thousands of cases of breast augmentation (including revisionary surgery for our own and other doctors' problems) do not "guarantee" success in preventing CC recurrence, doing everything possible and doing it in a scientifically-rigorous approach with meticulous technique is truly the way to go.

Or you will have a higher chance of asking questions here in an even more skeptical frame of mind before your third surgery! Best wishes! Dr. Tholen

Minneapolis Plastic Surgeon
4.9 out of 5 stars 238 reviews

Capsular Contracture

We don't know exactly what causes capsular contracture so it is difficult to prevent.  We do know that putting the implants under the muscle drastically decreases the risk of capsular contracture.  Other risk factors include: bleeding and infection.  So we always work to prevent these.  It is always frustrating to have to have another surgery for capsular contracture and you still have a risk of capsular contracture from that surgery as well.  Good luck!

What is Best to Prevent Capsular Contracture over or Under Muscle?

          This can be exceedingly complex.  I have prevented capsular contracture recurrence by shifting the plane to submuscular, extracapsular, subglandular with a change to textured, and with dermal matrices and without.  Find a plastic surgeon with ELITE credentials who performs hundreds of breast augmentation and breast augmentation revision procedures each year.  Then look at the plastic surgeon's website before and after photo galleries to get a sense of who can deliver the results.  Kenneth Hughes, MD Los Angeles, CA

The incidence of capsular contracture is no different above or below the muscle.

The most objective studies do not support a lower incidence of capsular contracture below the muscle.

Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon
4.9 out of 5 stars 32 reviews

Under the muscle

If you look at the data, it's pretty clear - implants under the muscle generally have a lower rate of capsules than implants over the muscle.  In terms of going larger, usually 25-50 cc is all you need to attribute to the removed capsule tissue - so a 600 cc would probably end up larger than your current size.  Best of luck!

Capsules after augmentation

The incidence of capsule formation is low with gel and saline implants. I would take out your implants, soak them in antibiotic soln., do a partial capsulectomy and put Alloderm in the defect, then replace the original implants beck in their pockets. Saline implants could be used after the alloderm reconst. . The advantage being the incidence of capsules is still slightly less with saline compared to the new gels,( but no definite long term results),but the texture of the breasts in patients with little breast tissue is not as good as gels.Even with alloderm capsules can recur, but the dermal substitute has been a big help to me in helping these patients.

Terry A. Cromwell, MD (retired)
Lafayette Plastic Surgeon
5.0 out of 5 stars 2 reviews

Whats Best, to Prevent Capsular Contraction. over or Under Muscle?

In general, placing an implant below the muscle (subpectoral most accurately, rather than submuscular) is believed to lessen the risk of a capsular contracture.  For implants above the muscle, using a textured implant is believed to have the same effect.  However, the process of capsular contracture is poorly understood (why, for example, will a patient get a capsule on one side but not the other when presumably the same procedure and decisions applied to both sides?).

Regardless, your situation is a little different because you already had implants (did you have a capsule - not clear?).  If your implants were 500 cc and were subpectoral and you developed capsules I would probably recommend staying subpectoral, not necessarily going larger, but consider adding an ADM (acellular dermal matrix), which may lessen the risk of a capsule and could have added benefits for implant coverage, which may be more important with a larger size.

Finally, though, your case is too complicated to offer a simple "second opinion" online; you'll need consults with one or more board-certified plastic surgeons to have a full and accurate assessment.

I hope that this helps and good luck,

Dr. E

Prevent capsular contracture?

Unfortunately, we don't know exactly what causes capsular contracture -- the hard scar tissue that can form around a breast implant which can be disfiguring and painful.  Many theories exist including concerns that capsular contracture may the be result of low-grade infection or other inflammatory process.  We do know that the rate of capsular contracture is lower when the implant is placed under the muscle.  I would discuss your concerns regarding the location of the implant with your surgeon.  Another consideration may be to decrease the size of your implant and/or consider a different type of implant (textured).  Good luck!

Anureet K. Bajaj, MD
Oklahoma City Plastic Surgeon
5.0 out of 5 stars 17 reviews

Whats Best, to Prevent Capsular Contraction. over or Under Muscle?

Always hard to answer these without photos. 

Based on the limited info available, I would disagree with two parts of the plan. Capsular contracture is less likely when implants are below the muscle, so I feel for this and other reasons it would be a mistake to put your new implants above the muscle. 

I also would recommend staying with silicone implants. At the size that you have, most of your breast volume will be implant, and the feel of the salines is very much less natural. There is not a difference in capsular contracture rate with modern gel implants and salines below the muscle. 

I agree with capsule removal. I don't think that enough capsule tissue will be removed to justify 100 cc increase in size, and a new capsule will be formed at any rate. Unless you want to be larger, I would stick with the current size. 

I would consider getting some additional opinions.

Whats Best, to Prevent Capsular Contraction. over or Under Muscle?

Hi Angie,

It sounds like you are having revisional surgery for capsular contracture. In general changing plane is recommended for significant capsular contracture but having it above the muscle with a larger saline does have its problems.

I would recommend a second opinion if you're uncomfortable with your surgeon's decision and would certainly look at textured or even polyurethane implants which may reduce your risk of having the capsular contracture recur.

Best wishes


Derek Neoh, MBBS, FRACS
Melbourne Plastic Surgeon

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