What would be lowest risk - new implants or fat transfer after explant due to capsular contracture?

Thanks for this question. If you have had capsular contracture in the past then the risk of developing it again in the future is increased, and breast implants in any setting come with the need for maintenance surgery in the future. Fat transfer may be a good option in your situation if you have adequate fat available for transfer. However, often more than one episode of fat transfer is required to achieve optimal results and so this does come with the risks associated with additional anaesthetics and surgical procedures. With fat transfer, once you achieve your aesthetic goals, I would not expect you to require future maintenance surgery. There are pros and cons of each and I would advise discussing these with a surgeon with appropriate expertise in revision breast surgery.

Once you have a capsular contracture the chances are very high that you will develop another capsular contracture.  Fat transfer utilizes you own fat to augment the breast making capsular contracture a nonissue.  

Capsular contracture is a complication that can occur after breast augmentation surgery, when the scar tissue around a breast implant tightens and hardens: ExplanationThe body forms a thin, pliable, and translucent capsule of scar tissue around a breast implant as a normal response to the foreign object. However, in capsular contracture, the capsule thickens and tightens, squeezing the implant and causing the breast to feel hard and painful, and look abnormal. SeverityCapsular contracture can range in severity from mild to severe. The Baker Scale is used to grade the severity of capsular contracture: Grade I: No contracture or asymptomatic Grade II: Mild contracture that is painless and almost undetectable Grade III: Moderate contracture with some firmness and discomfort Grade IV: Severe contracture that is painful and can be diagnosed by observation alone PrevalenceAbout one in six women who have breast augmentation surgery will experience some degree of capsular contracture. CauseCapsular contracture is caused by anything that leads to inflammation of the capsule. TreatmentPlastic surgeons can perform breast augmentation revision procedures to treat capsular contracture.

Hello, and thank you for your question. (Keep in mind that an in-person consultation is necessary for the best advice.) There are a few differences between those procedures. Breast augmentation with implants is a one-stage procedure (although subsequent revision, replacement, or removal procedures years later is common). To achieve fullness equivalent to a breast implant, fat transfer to the breasts usually requires multiple sessions/surgeries. But once these fat transfer surgeries are done, subsequent procedures are unlikely. That being said, both procedures have risks. You have to decide which approach is most consistent with your aesthetic goals. If you decide to pursue surgery it’s very important that you find a surgeon whom you are comfortable with and trust and who evaluates you in-person and tailors an individualized treatment plan for you and your aesthetic goals. Best of luck!
Matthew A. DelMauro, M.D.

Thanks for this great question. 
Once you have developed capsular contracture you are more likely to develop it again in the future after revision surgery than someone else having primary breast surgery. The only way to have zero  capsular contracture risk is to avoid breast implants. Under such circumstances, fat grafting is a good option if you are not ready to lose all of the volume that your breast implants were giving you. This operation has its own name - SIEF (Simultaneous Implant Exchange with Fat). 
Interestingly, my impression is that there is better fat graft take during SIEF than during fat grafting of a previously unoperated breast - this might be due to having expanded the breast tissues and skin by the implant. Fat grafting is not without its own potential problems, including early volume loss (around one third), the need to undergo liposuction and to have enough fat "donor" somewhere to do so. However this may be a good option for you and is worth discussing in person at a consultation to assess your suitability. Good luck! 

If you have had capsular contracture once, there is a slightly higher risk of developing it again, which would be unfortunate since you already underwent surgery to treat it. Fat transfer could potentially get you to your goal, but it depends on how much fat you have to transfer to your breasts. You may also have to have more than one procedure.

With a fat transfer, you are using your own tissue. However, the results may vary, even between the two breasts. Most gain one half to one cup in size. If you loose weight, you run the risk of loosing some of the transferred fat. The risks of fat transfer include possible oil cysts and areas of scar tissue, fat necrosis. With implants, you know what size you have and the size of the implants remains stable. There is a higher risk of capsular formation with the second implant after one from the first. But, polyurethane implants did pose a higher rate than the new gel and saline implants. I would suggest meeting with your surgeon and discussing the pros and cons of both.