43, 5'8, 136lbs, 385 & 355cc too big & rippling, what is possible for my situation? (Photos)

Of course you have problems with implants placed over the muscle. The simplest solution would be to change your current underfilled Sientra implants with either Natrelle Inspira with their cohesive gel or, my preference, with Motive Round implants (the higher cohesive of the two gels they offer). This is not a sure thing, but ripples should be improved. Alternatively, get a more invasive revision surgery to place implants under the muscle, where I think they belong, even in young, athletic people.

Dear betterthanbefore,
Breast revision surgery is the most difficult plastic surgery procedure performed. Botched breast surgery alters normal tissue planes and laxity, the ability of breasts to heal properly, and leaves scar tissue that dramatically affects the level of difficulty of the corrective surgery.Many patients come in to correct poor outcomes from their initial surgeries. The most common problems are due to implant malposition, bottoming out of the implant, poor scarring, and incorrect implant size.While the type of revision required will depend on the result of the previous surgery and the desired result of the patient, some revisions involve extensive pocket repair that may or may not need specialized external bras.If you are considering breast surgery revision, you should speak with a board certified plastic surgeon and have yourself properly assessed. Only after a thorough examination you will get more information and recommendations. Also, you have to make sure that your surgeon understands your breast augmentation goals.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

I think you will be happier going down about 100 cc's. Using gel implants gives less rippling. I prefer behind the muscle for better upper breast fullness, more support to the implants and less rippling. Being in front of the muscle , you now have more sag and might need a lift.