Follow Up Implants Still Too Far Apart and Under my Arm. 3 Months Post Op. What To Do? (photo)

Textured implants are designed to adhere to the tissues, which is one reason I believe textured implants have no place when used below the muscle. Textured surfaces were developed in the late 1980's when most implants were placed below the breast (ABOVE the muscle) and there was a much higher incidence of capsular contracture.

We now know that CC occurs primarily in the settings of bleeding and bacterial biofilm formation. Below the breast positioning (above muscle) exposes the implants to significant numbers of intraductal bacteria, and smooth implants in this location allowed the bacteria to move freely along and around the smooth implant surface. Implant surface texturing provided adherence, isolating bacteria into localized macro-pockets between the irregular textured surface peaks and valleys, while also "breaking-up" vector forces of collagen and myofibroblast contraction. Some studies have shown that texturing seems to reduce capsular contracture in submammary implant placement; other studies are less convincing.

When the FDA restricted use of silicone gel implants in 1991, plastic surgeons were forced to use primarily saline implants for cosmetic augmentation, but when used in the above-muscle position most of us were "used to," patients began to notice rippling and water-balloon feel, so most plastic surgeons started placing implants below the muscle. Including those who used textured implants above the muscle.

However, below the muscle there is significantly less bacterial contamination, since the breast ducts are above the muscle. Less CC occurred, and some PS felt this was due to their use of textured implants rather than the much-lower bacterial load of the submuscular position. However, some degree of lateral breast movement is natural when reclining, and only smooth implants allow that. Textured implants cannot move, and only the (small amount) of your own natural breast tissue moves, even less so if you have CC.

I am explaining this so you understand that even though it is a surgeon's (and patient's) choice as to smooth or textured, and above or below the muscle, there should be some degree of thought and reasoning behind the decision other than "This is the way I've been taught" or "That is how my professor did it" or "that's what my girlfriend has and hers look nice." Habits are bad when new information or better science goes unnoticed. Clinging to old ideas out of stubbornness or "routine" is equally wrong. But back to you.

Your implants are too narrow (full projection=high profile) for your breast base width, giving you the "curve and swell" under your arm and the wide cleavage you mentioned earlier. Texture has prevented them for dropping into better downward position over time (as smooth implants would), and rippling is evident because your implants are soft and you have not developed CC. Even silicone implants can have some rippling, though generally much less than saline, and much less than above the muscle.

Your result isn't bad, but you aren't happy either. You would have better results with smooth round implants below the muscle in a wider profile implant choice. If you like your size, then (for sure) you need mod + or even wider moderate profile implants; if you would prefer bigger, then the larger implant size will have a correspondingly wider base and moderate may still be best, or more likely a moderate + profile.

Time won't help your result because of the adherence of your textured implants--they can't "settle" or drop into better position, not to mention being better in the cleavage area or less in the under arm areas. I'm sorry to tell you that revision seems to be in your future if you remain unhappy with your present appearance. I'd suggest consultation with additional ABPS-certified plastic surgeons experienced in breast surgery, and hear their philosophies about the choices they make, and why. For more information, click on the web reference link below. Best wishes! Dr. Tholen

Your questions and difficulty with the implants are not uncommom, but I believe must be evaluated carefully in person, preferably by the operating surgeon, to develop a treatment plan that is most likely to suceed.   You submit good photos, but there are multiple technical aspects of surgery the online responder cannot know.  In general, to keep implants from lateralizing in supine position, textured implants good choice.  Width of implants should be broad enough to extend close to midline, as your pre-operative breasts do.   Positioning implants at surgery mandates slight medialization relative to your lateral nipples.  Post surgical bra to prevent dynamic muscular lateralizing force and close post surgical follow up to be certain of satisfactory developing result also important, in my opinion.

Thank you for the question and pictures.

If you find that your breast implants displace laterally ( especially when you lie down), you may benefit from revisionary breast surgery at some point. This operation may involve internal sutures placed along the sides of the breasts (lateral capsulorrhaphy).  Closing off the breast implant pocket on the sides will serve to prevent breast implant migration to the sides (laterally).  Judicious opening of the breast implant pocket mediallly ( close to the cleavage area) may also help improve the breast implant positioning and your level of satisfaction with the results of surgery.

I hope this helps.

The photos demonstrate a pre operative asymmetry that was not considered in the choice of same sized implants. As for the supine lateral displacement I find your result acceptable. You need to discuss why the same size implants were used in an asymmetric volumed breasts (left was smaler than right and higher inframammary crease)

First, you are limited by your anatomy a bit.  In addition textured implants do not move as easily as smooth implants. Some uneveness is also normal as the breasts start off a bit asymmetric.