I am exchanging 20 year old Saline Implants with 450cc Gummy Bear Silicone. Should I go above or below the muscle? (photos)

16 years ago at the age of 20 I had 230cc textured saline implants placed above the muscle. I have since breastfed 3 babies. In two weeks I go in for an exchange. I originally wanted to switch to under the muscle. Surgeon suggests over now at my pre op.What do you think?

Doctor Answers 15

I am exchanging 20 year old Saline Implants with 450cc Gummy Bear Silicone. Should I go above or below the muscle? (photos)

If you are  on top of the muscle and have had no issues I see no reason to go under. With  your current shape being somewhat ptotic going under the muscle would put you at a higher chance of getting a double bubble deformity.  I fear that with the gummy bear implants a higher risk for spinning in the pocket unless  your capsule is removed, however.  My preference would be a high profile round gel device.  Sientra has a device that is high cohesive and round.  Obviously work closely with your physician to determine the best implant for you. 

Replace breast implants with larger size

It is always best to follow the specific advice of the plastic surgeon who is performing your surgery.  I assume that the surgeon is concerned that if your new implants are placed beneath the muscle the stretched breast skin from your prior implants will not adequately redrape over the new sub-muscular breast mound.  It is best to follow your plastic surgeons advice.

Implant Position Choice

Thank you for your question and photos.  Subglandular pockets are associated with a higher long term risk of wrinkling, palpability, capsular contracture and implant malposition. While you have done well with your saline implants for years, increasing the size of the implant can cause issues to arise that were not a problem with smaller implants. Switching to silicone will reduce your risk of wrinkling and palpability.  For the lowest risk of long term issues, the submuscular pocket does provide some advantages. It is a more involved procedure than just replacing your existing implants so more time will be required. Discuss the pros and cons of your decision with your surgeon. Best wishes.

New gummy bear implants

Thank you for your pictures. If the gummy bear implants are anatomic then they should go into a new pocket which would be under the muscle. The pocket for anatomic implants must be very precise. If the gummy bear implants are round then they can go in your original pocket. This is something that the plastic surgeon should figure out and discuss with you. Good luck.

Exchanging my implants? Should I stay on top of the muscle or go under?

The two main reasons to go under the muscle are to camouflage the upper edge and possible wrinkles of the implant, and for a lower risk of capsular contracture.  If have not had visible wrinkling in the upper pole of the breast even with textured saline implants (perhaps the implants that wrinkle most), then you probably have think enough tissue that it will hide potential wrinkling of textured silicone gel implants.  And since you apparently have not had issues with capsular contractures, you certainly could consider staying above the muscle with your implants.  Given your photos, I am not sure that shaped implants are going to be of much benefit, and as a secondary case you may be at greater risk for an implant turning in your pocket...you might consider round textured cohesive gel implants.

Implant pocket

 In general, I prefer to go under the muscle.  If you have not had problems with over the muscle then it is fine to proceed that way as well.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

To be above or below

Hi youngbksy, So, why are you changing out your implants? Do you not like your size or shape? Are your breasts sagging? Do you want more projection? Possibly all of the above? You are obviously going bigger with a 450 cc "Gummmy Bear". Are you using a shaped implant? There is no reason to exchange a saline implant if your ok with things unless you want to correct them after babies.....There has been some deflation of the breast tissue and some internal correction may be needed too....The decision to stay above versus going to a sub-pectoral muscle plane should weigh the tradeoffs of each. Recent studies show a significantly higher rate of capsular contracture with sub glandular/pre-pectoral breast implants versus sub-pectoral implants; contractures occur with the more cohesive implants too. There is also more thinning out of the breast tissue over the years with above muscle versus sub-pectoral implants. With above muscle implants, you may see and feel the implants much more and there can be more rippling; and there is rippling even with the highly cohesive implants. It is possibly true that there will be more surgery by placing the implants sub-muscular but there is a significant change of size of implant and it may not be a problem. It might be necessary to place a material such as Seri or Strattice to reinforce the lower pocket too but this may help if above muscle too. I am a proponent of sub-muscular implants because they have less long term problems then as noted with above muscle implants and they look more natural. If you are going with shaped implants then you will need total capsulectomies anyway. Creating a sub-muscular pocket doesn't take that much more time but if it is necessary to use a reinforcing material, this involves the expense of the material and the cost of the time to put it in. Shaped implants require a tight fitting pocket to maintain their position and counter rotation of the implant. We have a Vectra 3D imaging system that is a great way to look at the breast after a larger size; to best answer your questions, a clinical evaluation is necessary. 

Implant Exchange Pocket Location

In a situation like yours, I only recommend changing the pocket location if there is a problem like capsular contracture, rippling, or palpability. Creating a new subpectoral pocket can help if these issues are present, but creating a new pocket also involves more surgery and sometimes creates its own problems. Bottom line, I don't recommend changing implant sites unless there is a reason.

In front or behind the muscle for breast augmentation

Your question is a really good one and something that we often are asked when patients come in for implant exchanges.  In general, the pocket behind the muscle offers more cover to the implant and in many studies a lower risk of capsular contracture, which is often why we now use it for augmentation.  If your current pocket in front of the muscle is doing well (soft without contracture, no rippling, good shape and support) you could certainly consider keeping the same pocket for your new implants, but this is something that you and your surgeon can discuss in detail, including how the pros and cons of each option.  Other points to discuss with the surgeon include the quality of the soft tissue support and whether or not more support would be required (in the form of for example Seri silk scaffold or Strattice, to name a couple of examples), incision placement, etc.

Thanks for the question and good luck!

Shahram Salemy, MD, FACS
Seattle Plastic Surgeon
4.9 out of 5 stars 142 reviews

Breast imolants replacement, should we make a new pocket?

You have to options, one of them is to maintain the same submuscular pocket and just place a new bigger cohesive gel implants that won't lift the breast and also at the sametime to do a vertical mastopexy. The other option should be to place the new implants under the fascia in a new pocket and lift the breast at the same time with a vertical incission also. Try to choose an ASAPS member Plastic Surgeon.

Luis Lopez Tallaj, MD
Dominican Republic Plastic Surgeon
5.0 out of 5 stars 2 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.