Previous Capsular Contracture from Under the Muscle. Should I Go over the Muscle or Do Fat Grafting?

I had a previous contracture in both breasts about 10 years ago. Implants were placed under the muscle. They were removed a year later and did not replace them. I've seen 2 surgeons. One recommended fat grafting the other recommended placing a silicone implant over the muscle. Worried that the grafting will give uneven results. Also concerned about the higher possibility of contracture in over the muscle placement. Both doctors felt these possibilites were the best answer. Thanks!

Doctor Answers 8

Revision breast surgery

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I think your breast gland tissue has descended below the ideal position, more notably on the left than on the right. This gives the illusion that your nipples are too high, which they are in comparison to your fold under the breast, even if they are not too high with respect to your collarbones.

I think you would be well served by revising the lift component of your result by tightening the skin, reducing the excess on the lower pole of the breast, and, if necessary, lifting your nipple into a better position, followed by new implants in what is called a "neo-subpectoral" pocket. This means that the old capsule of your implant pocket would be separated from your muscle and sewn down and the new pocket made under your muscle from scratch. Sometimes this is supplemented by the use of acellular dermal matrix (like Strattice or other similar products) to support the lower pole and prevent the new implant from descending.

Fix the stretch deformity first

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Your photo appears to demonstrate a "stretch deformity", i.e. increased distance between nipple and inframammary fold, especially on the left side.  In addition, the axis of your nipples are laterally (outwardly)displaced.  Like the other consultants, I think you would benefit from a breast lift (either primary or revisional) to tighten the skin brassiere first but also potentially improving both the lie of the nipples as well as the positioning of your native breast tissue.  By staging this procedure, first, you may be able to assess whether this is sufficient to satisfy your aesthetic objectives. 

Once the skin brassiere is optimized and you desire further volume, I would second Dr. Baxter's suggestion of a dual plane silicone gel implant with either Strattice or Alloderm.  You'd get the dual benefits of implant stabilization as well as a protection against capsular contracture.  Experience with structural fat grafting to cosmetic breast patients isn't as established as for breast cancer cases but the fact remains that the patient must have an adequate quantity of fat to harvest.  I'm not sure that your body habitus would support this need.  Good luck.

Lavinia K. Chong, MD
Orange County Plastic Surgeon
4.8 out of 5 stars 58 reviews

Breast issues

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I am not sure of your question. Fat grafting can help to increase volume or camouflage some irregularities.  If you want to revise the lift, that can be done as well.

Previous Capsular Contracture from Under the Muscle. Should I Go over the Muscle or Do Fat Grafting?

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If you are happy with the volume of your existing breast tissue, I would recommend that you have a revision mastopexy where your own breast tissue can be moved to a higher position to give you the upper pole fullness you need, as well as decrease the distance from the nipple to the infra-mammary fold.  If you want fuller breasts, you will still have risks of capsular contracture, as that is the nature of implants; you can consider fat transfer, however from your photo, you appear thin, so this would only work if you have the fat to transfer! Good luck.

Fat grafting and breast lift will work

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You have mild Pseudo ptosis and also loss volume in upper pole of the breast, The combination of the fat grafting and mastopexy will give the best result.  Please make sure that your plastic surgeon is qualified to do the large volume fat grafting . You will need about 300 cc of fat grafting each breast.

You have significant bottoming out of your breast tissue, to improve your breast you need a breast lift with or with out implant

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Your breasts in the photos show a high ridding nipple areolar complex in relationship to your breast mound. Most of your breast tissue seems to have migrated below your nipple or as Dr. Baker has questioned, you have had a mastopexy, breast lift, with your nipple being placed too high. Fat grafting is a great new technique to enlarge your breasts but will not correct the position of your nipple. From what I see in your photos, you would be best served with a breast lift to reduce the breast fullness below your nipple, not to elevate your nipple and a breast enlargement with a textured silicone gel implant under your breast. If you are willing to under multiple procedures than may be you could be enlarged with fat grafting which precludes the need for an implant. 

Prior Capsular Contracture

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New implants will again be at significant risk for contractures, but one never knows.

If you choose to have implants again, I would place them below the pectoral muscle.

The picture suggests that you may  have had a breast lift.  Without or with an implant, your shape could be improved with further skin tightenting, i.e. a secondary breast lift, or a primary lift (if you never had one), esp. on your left side. You might try this first before taking another chance with implants.

Stephan Baker, MD
Miami Plastic Surgeon

New implants after previous contracture

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Without seeing you personally, no one can make a definitive recommendation, but I do have another option that would be worth considering: go under the muscle and use Strattice grafts for an internal bra. My expreience is that Strattice is very effective at preventing capsular contracture, and it would add support for the implants as well.

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.