Dana Goldberg, MD

This looks like a small area that should respond well to scar revision and should be easy to tolerate under local anesthesia.

Areola size and shape can be adjusted with a revision, but sometimes the skin stretches unevenly, leading to an imperfect result despite a smooth surgery and good immediate post op result. Significantly upsizing the implants will lead to more stretching after surgery, so sometimes it is safer to upsize implants, let the skin stretch, and then come back to reshape the areola under local anesthesia several months later. It may be possible to do both together, but that depends on the size you are aiming for and also the amount of tension on the existing scars.

A crescent could help the areola appear slightly higher on the breast, but in my experience it would not lead to smaller areola size. I agree that a non-dissolvable (or permanent) stitch increases the likelihood that the areola will stay small, but there is a small chance of that suture becoming exposed or infected in the future. In my experience, this risk is small, and it's usually easy to address under local anesthesia if it becomes an issue at any point.

After 11 years, the appearance could be due to sagging of your own breast tissue over top of the implant or it could be a sign of capsular contracture. This occurs in about 6-10% of patients with implants and refers to tightening of the scar tissue around the implant that can eventually cause it to become firm and to sit higher on the chest. In turn, this causes the nipple to look lower. It's usually triggered by bacteria in your own body that creates inflammation around the implant, and it can occur at any time after implants are placed. An in person exam is the best way to determine what is going on. If it is just that your breast tissue has sagged, then revising your breast lift and changing out to a smaller implant may achieve all your goals. If it is due to capsular contracture, the surgery is more extensive because all the scar tissue must be removed. Typically, a tissue graft is also placed to support the implant after the capsule of scar tissue is removed and because studies show that using a graft in this way reduces the chances of capsular contracture coming back. With the way you describe what has happened (the tops being higher and the left having a dent at the bottom), I'm more inclined to think it is capsular contracture. This isn't harmful to your overall health, so it isn't an emergency,

I do not think you need flank lipo from the photos. Often, I’ll perform the tummy tuck, and if there is a little fullness near the ends of the incision, a small amount of lipo can be done from the front. Formal flank lipo is usually performed with you positioned on your sides or on your stomach. This adds to anesthesia time, and I don’t think that extent of lipo is needed.

Under eye hollows can be genetic or age related, but there are solutions. A common approach is injection a hyaluronic acid filler to add volume. This lasts 6-9 months. There can be bruising after the injections, so I recommend finding an experienced injector that uses cannulas instead of needles. Some products can lead to a bluish discoloration under the skin, but we have a lot of success with Restylane in that area. If you want something more natural, you can have far grafting, which involves using liposuction to remove a small amount of fat from the abdomen, hips, or thighs and transferring it under the eyes. That is a fairly permanent solution. There is also PRP (platelet rich plasma), which involves drawing blood, spinning it down in a centrifuge, and then injecting it. This doesn’t provide as much volume, and it’s temporary, but it has very few risks or side effects and could give you an idea if you like the look of more volume in that area. There is also a commercially available product called PDGF which is a lab version of the PRP that’s even more concentrated with growth factors that can add volume to the area. The appearance will get worse as you age, so eventually under eye surgery could be indicated in your 50s or 60s as under eye bags accentuate the hollow underneath, but there are plenty of options before then. Best wishes.

I agree with your surgeon in this situation. The porn star look comes from an implant that is much larger than the base width of the breast and generally occurs in patient with little to no breast tissue to cover the implant. I think the higher profile will help give more of a perceived lift and could still look extremely natural. Best wishes for a great result!!

I would maximize the width of the implant. However, if you increase the width of the implant too much, you could risk a double bubble effect (seeing the natural border of your breast in addition to the border of the implant). This depends on how tightly defined your crease under the breast is. If you have enough fat to transfer, this can help minimize double bubble as well as maximize cleavage.

I have never heard this about Xeomin, and it doesn’t make much sense to me scientifically. For the money invested over 1-2 years, you could explore other options like laser resurfacing, microneedling, or ultherapy. They don’t do the exact same thing but are other modalities that could reduce fine lines and wrinkles.

At this point, you will not get the best result from a tummy tuck because there is still enough intra-abdominal fat (fat behind the muscle layer inside the abdomen) that you will not have a flat stomach even with a tummy tuck and liposuction. After further weight loss, you will be able to get a flatter stomach and a better result. Also, the risks of the procedure are lower when patients are at a lower weight. I have had a few patients choose to do a panniculectomy (which is just removal of the lower skin that hangs) in order to improve their comfort and allow them to be more active while they continue to lose weight. This is a more minor procedure than a tummy tuck, and a full tummy tuck could always be performed later once weight loss is complete.