Surgeon recommends 2 options: 1. Surgery to "stitch up" bulging part of pocket, repositioning it or 2. Superficially cut a section of the "bulging" area, pull nipple over, and stitch up, making it appear symmetrical. He recommends option 2 b/c he said cleavage I have now is good. He never mentioned anything wrong (e.g. contracture) & gave no reason for asymmetry appearing 3 months post-op (just said it could be many reasons). Any opinions/advice on these two options would be greatly appreciated.
Asymmetry/Bulging Noticed 3 Mo Post-op (Surgery Date 8/2012). Surgeon Recommends 2 Options. Advice/Opinions Requested? (photo)
Doctor Answers 8
Do NOT try to reposition your nipple!
If you go back and look at your preop photo, you will see that you had some breast and chest muscle asymmetry to begin with. Most likely this led to overweakening of your pectoralis on the right, which has allowed the right implant to cross over the midline. This in turn has caused the right nipple to "veer off" laterally and appear out of place. THIS IS NOT A PROBLEM WITH THE NIPPLE POSITION. I have seen this flawed thought process more times than I would like to mention, and once a surgeon has tried to "reposition" the nipple from the outside, the scars are there, and nothing can be done about that. In the end, the problem still exists because the actual cause - the malpositioned implant pushing the nipple to the side - has not been addressed. The correction for this, while not necessarily simple, is very straightforward and involves a tightening of the capsule from the inside only. Option #2 should not even be on the table, and I strongly disagree with your surgeon that your cleavage is "good." It might be full, but it is asymmetrical, and your right implant is out of position. If he disagrees with this assessment, my advice is to seek another opinion.
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I am so sorry that you are having this problem after a fairly normal, uncomplicated surgery. Your appearance today seems to show significant implant malposition medially, as well as superiorly, and that the lower outer pole of the same breast is 'underfilled'. Why it occurred is unknown, but there is a subtle hint looking at your pre-surgical photo that suggest asymmetry to the breasts, with the affected one having very little lateral tissue, and very tight appearing skin. Alternatively, there may be a minor element of contracture too.
All of the issues, including nipple malposition, will be rectified with implant repositioning laterally and inferiorly. This can be done entirely through your current inframammary incision, by a number of different techniques that would be chosen by your surgeon, depending on his experience.
What's important to know is there should be no external excisions of skin to rectify your nipple malposition.
Best of luck!
Correction of implant malposition
Your pre-operative photograph shows some skeletal asymmetry and I would not be surprised if you have some degree of scoliosis. There are marked differences in the shape and contour of your anterior chest wall and rib cage. Your early post operative shape looks good but at three months it appears that the right breast has migrated too far medially almost across the midline. I can not tell if your augmentation was subglandular or submuscular. In any event the midline has shifted tot he left. A correction of this abnormality would be a capsule repair or capsulopexy in addition to a release of the lateral capsule to allow the implant to move over. I would not recommend, from viewing your photographs, a re- positioning of the nipple and areola.
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Asymmetry after breast implants can be fixed.
The right implant pocket goes past the middle into your left chest. This part of the right pocket needs to be closed off FROM THE INSIDE with stitches. No additional scar. This is called a capsulorrhaphy, and it works. I suppose that is your option #1. Would definitely discourage option #2.
Asymmetry/Bulging Noticed 3 Mo Post-op
It's hard to say for sure from these photos (the recent seems to be slightly off from straight-on) but, based on these, you appear to have migration of the right implant a little too far medially. This can happen for many reasons but is generally more likely for implants that are relatively large for the frame. If you are otherwise happy with the size and the look on the left side then I would probably advise opening the pocket on the right side a little more laterally and sewing off the medial limit. However, if the pocket is tight then the sutures may not hold. Adding an acellular dermal matrix, or changing the pocket (if applicable) may help, as can using a smaller implant (although you would then need to have both sides redone). This decision should, of course, be made after more discussions with your plastic surgeon.
I hope that this helps and good luck,
It's difficult to answer this with such limited information. You had obvious asymmetries pre-op which your surgeon tried to correct. Your right implant pocket has been overdissected medially into the cleavage area. If your implants are above the muscle, this could eventually lead to a synmastia (or "uniboob"). If you were my patient, I would try to move your right implant out further laterally by opening up the pocket laterally and stitiching up the pocket in the cleavage area. By doing this, it will tilt your right nipple inward and make it look more like the left side. Repositioning the nipple alone (as you describe above) is a "band-aid" approach that will not give you good symmetry. The problem is the implants are not symmetrically placed so that's what needs to be addressed. Hope this helps!
Medial implant displacement
This is a frustrating complication for the patient and surgeon both. From the look of your early post photos, you seem to have gotten a great result. Sometimes implants seem to heal like they have a mind of their own. I would definitely NOT do an external incision. That would look much worse than what you have. What you need is to have the lateral pocket released and the medial pocket tightened a bit. I have my patients wear a thong bra afterward. That is essential.
Option#2 Bad Bad Idea by Villar
You have disruption of the sternal attachments. Whether you have over or under the muscle location of the implants is important in developing a plan of action to fix this, but DO NOT LET ANYONE CUT OUT SKIN TO FIX THIS!!!
I would be happy to give you advice and even speak to your surgeon, but this can be fixed from inside the breast. Best wishes. Knowledge is power. Luis F. Villar MD FACS
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