High-Riding Saline Breast Implants: Mechanical Malposition Rather Than Capsular Contracture? A 23-Year Single-Surgeon Experience and Proposed Refinement of Baker Grade III.

backgroundSuperior implant malposition ("high-riding" implants) is commonly attributed to capsular contracture and frequently treated with capsulotomy or capsulectomy. However, clinical experience suggests that superior displacement may occur in the absence of pathologic capsular thickening. Misclassification may lead to unnecessary capsulectomy and increased operative morbidity.

objectivesTo characterize the clinical presentation, intraoperative findings, and operative management of patients undergoing surgical lowering of high-riding breast implants and to determine whether this entity represents a mechanical rather than inflammatory capsular process.

methodsA retrospective review was performed of 209 consecutive patients who underwent implant lowering for superior malposition between 2001 and 2024 by a single surgeon. All implants were saline. All patients had revision surgery by lower capsulotomy alone or with a limited lower partial capsulectomy. Demographic variables, parity, ptosis status, nipple-to-crease (NTC) distance, implant characteristics, time from augmentation to revision, and operative times were analyzed. Intraoperative capsular characteristics were documented in all cases.

resultsTwo hundred and nine patients underwent lowering procedures (82 right [39.2%], 54 left [25.8%], 73 bilateral [34.9%]). Mean age was 39.8 years. Mean implant size was 429 cc (range 275-600 cc). Ninety-six patients (46%) demonstrated ptosis (mean NTC 8.0 cm) compared with 6.11 cm in non-ptotic patients (n=113). One hundred twenty-six patients (60%) had children. Mean time to revision was 13.3 months (range 6-66 months). Mean operative time was 43.7 min for unilateral and 70.8 min for bilateral lowering. All cases demonstrated a normal fibrous capsule intraoperatively.

conclusionsSuperior implant malposition requiring surgical lowering occurs predominantly within the first postoperative year and, in this saline cohort, was uniformly associated with a normal capsule. These findings support the hypothesis that, within this saline implant cohort, superior implant malposition is predominantly mechanical rather than inflammatory in origin. Recognition of this distinction may refine operative decision-making and reduce unnecessary capsulectomy. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 . KEY MESSAGE: Superior implant malposition does not necessarily indicate pathologic capsular contracture. In this 23-year saline cohort, all high-riding implants demonstrated a normal fibrous capsule intraoperatively. Mechanical factors-rather than inflammatory contracture-may underlie many cases of Baker Grade III distortion. Recognition of this distinction supports targeted pocket modification and capsulotomy rather than routine capsulectomy.