Braden C. Stridde, MD (license expired)

You photos suggest that you have very thin tissues with minimal breast tissue. It would be a bad choice to place an implant in the subglandular/subfascial plane. Underneath the muscle, or more correctly, dual plane placement would be much more advisable. In fact you have so little tissue that consideration should be given to using an anatomic or shaped gel implant in order to achieve a more natural looking outcome. In someone like yourself even a moderate sized round implant under the muscle can look like an unnaturally round ball on your chest.

The discomfort and/or change in your breast shape with muscle flexion is something called animation change or animation deformity. It is something that can occur when implants are placed under the muscle but it should be a rare or minimally noticeable problem if your surgery is performed carefully. Things that can make this problem worse include saline implants, smooth surface implants. larger implants, and certain variations in the specific anatomy of a patients muscle.

I assume that your photo is of a mirror image because it is your right breast that appears abnormal in the photo. On the affected side on there is greater animation change and visible rippling. This is a result of over release of the attachments of the pectoral muscle along your sternum. This results in excessive "windowshading" of the muscle upwards when it is contracted, and if allows your implant to shift towards the midline with subsequent thinning of the tissues and visible rippling. This would not be considered "normal"

No kidding. So you went to Costa Rica to have your facelift for less money and now you have terrible complication. Is this a surprise? I, like a high percentage of my Plastic Surgeon colleagues, have seen a depressingly large number of ugly complications from plastic surgery performed in exotic locations (Costa Rica, Mexico, Dominican Republic, Thailand, Korea, to name a few). What happened to the white sand beaches, swaying palm trees, and solicitous caretakers that are advertised as being part of the deal when you travel to places such as this to have plastic surgery - and at a fraction of the cost here in the good ole U.S.

Unfortunately, what so many patients fail to understand is that the cost of your post operative care here in the U.S. is factored into the cost of your surgery. So if you have a complication the costs of managing that problem will be covered at little or no additional cost. This accounts for a big part of the cost differential between having your surgery done here or in some bargain tropical location (that and the big difference in standards for physician training, facility operations, and ancillary care). Surgeons operating in far flung destinations don't have to factor in the cost of any longer term care, so they can charge less. But it is at your expense when things don't go as planned (something that is far more common then you would like to imagine).

There are any number of highly trained, experienced, thoughtful, and caring Plastic Surgeons in the Seattle region who could have performed this surgery for you, and I would argue, at lower risk of these types of nasty outcomes. That is not to say that something like this couldn't have happened here, but if it did, you could reliably know that you would be taken care of. Instead, you chose to treat the surgeons of Seattle with complete disdain and decided to venture abroad, because, almost always, it was less expensive. So now what?

Is it your hope that a local Plastic Surgeon will now take on the responsibility of caring for someone who has experienced a disfiguring complication from a surgical procedure that was performed by some unknown surgeon in a foreign country? There is serious disincentive for anyone here to consider doing that. First of all, you paid someone else to do your surgery. How are you planning to compensate someone here to provide ongoing care. They are taking on a big responsibility and the outcome is uncertain. But if they do agree to take on this responsibility they are taking on a daunting obligation, because the U.S. medical and legal systems will hold them responsible for providing the highest standards of care (again that is not something that applies when you venture abroad).

I am sorry that you have had a bad complication. I would not want that to happen to anyone and you now have a difficult journey ahead of you. My suggestion is that you return to the place where you had your surgery and have them take care of the problems that they created. It is a long honored principle of medical ethics that a surgeon should take responsibility for any untoward outcome of surgery that they have performed and help the patient to recover to the best possible outcome. If that is not an option then you might find a kind local plastic surgeon who may agree to help you through this. You should not expect that care to be provided at no cost. The other commonly unreported component of surgical tourism, is that if you require ongoing care on your return to the U.S. the ultimate total cost can end up being many times more expensive then if you had had your surgery here in the first place. 

The problem of multiply recurrent capsular contracture is exceedingly frustrating for both the patient and surgeon, and unfortunately there are no guaranteed fixes. This is why it makes sense to take every precaution to prevent capsular contracture from ever occurring in the first place.

Four operations and three capsulectomies in a year seems a bit excessive. It doesn't make sense to keep repeating the same operation over and over and expecting to get a different outcome (What is the definition of insanity?). The so called "Aspen" treatment is promoted as some new breakthrough in the treatment of capsular contracture - it is not. In my opinion it is simply a gimmick to extract more cash from patients who are desperate for an answer to their problem of capsular contracture. Ultrasound has been used for over a decade as a way to soften capsular contracture. While it can produce a short term improvement the problem always returns because the underlying cause is not addressed. 

When one gets to the point of multiply recurrent capsular contracture a distinctly more comprehensive approach must be taken to have any of hope of solving the problem. This means removal of old implant and replacing with new implant (possibly textured), total capsulectomy, and either the addition of ADM (Alloderm or Strattice) or not replacing the implant and allowing the inflammatory process to resolve for six months or longer before replacing the implant with or without ADM.

Breast massage post augmentation is completely unnecessary. It is uncomfortable and unless the seems to not be settling into place it is of no benefit. In addition it does not prevent capsular contracture. But if your surgeon insists you should ask them to instruct you on technique.

You are quite correct in your understanding that it is not a good idea to use large implants when doing a lift at the same time because there will be an excessively high rate of complications or poor results. It also a bad idea to use large implants with a Benelli type of lift because it leads to an enlarged areola and poor scars. Also, in general it is not a good idea to try to use a large implant in an effort to avoid a lift because it will result in a large low positioned breast with thinned tissues that don't support an implant which will only go further south over time. 

From your photo it looks to me like you could do a lollipop type of lift with a more moderate size implant in a single stage. If you have a large frame then you may be  OK with a larger implant but it is important to remember that breast augmentation surgery does not repeal the law of gravity. 

It depends on how you define it, but some amount of blood within the implant pocket would be considered a hematoma, although there may not be enough to be seen as a significant mass on ultrasound. Your history suggests that you had some late bleeding after your breast augmentation which was self limited, but not trivial, because there is obvious swelling and your right implant is clearly higher. Bruising can take some time to show up as the blood gradually disperses through your tissues. If some time has passed between when you first experience symptoms and when the ultrasound was done then the blood may indeed be dispersing into your tissues.

This is a judgement call. While the ultrasound may not show much now, it does appear to indicate that there is some blood present within the pocket. Leaving that blood unaddressed could definitely lead to capsular contracture down the road. Given that you clearly have had some significant changes in your right breast with at least some blood in the pocket I think the prudent thing to do would be to reopen the right side and wash out any blood that is present. Neither surgeon nor patient would be eager to do this but fixing capsular contracture later will be a much more involved procedure.

Unfortunately, just about everything that could go wrong with a breast lift with implants has gone wrong for you. It is important to recognize that the simultaneous combination of breast lift with implants has a very high complication and revision rate. The risks are even higher if a major lift is needed or a larger implant is used. 

You actually haven't provided us with complete information and looking at your previous posts it appears that you also had a tummy tuck at the same time as your breast surgery. This completely explains why your breast scars are "stretched". If the skin is undermined too high or pulled too tight with a tummy tuck it will pull down and displace the scar under your breast. This is why they appear so "stretched". You also appear to have capsular contracture of both breast implants which results in the implants being displaced upwards which only worsens the overall appearance of your breasts. 

One of your problems is impossible to correct and the other one typically very difficult to consistently fix. The displaced and stretched scars cannot be repaired because the skin is too tight. This was an error of poor judgement and execution of  your tummy tuck. Capsular contracture can be fixed but there is a high recurrence rate if it is not done properly. You should see a Real Plastic Surgeon who has lost of experience with revision breast surgery.

Given the truly poor outcome from your surgery it raises the question as to whether your surgery was performed by a Real Plastic Surgeon, i.e. someone who is certified by the American Board of Plastic Surgery. Unfortunately there are many unqualified physicians who have reinvented themselves as "cosmetic" surgeons but who do not have the education, training, and experience to deliver consistent quality results in aesthetic plastic surgery.

I would start by asking what side looks better to you. Based on what we can see from your photos your right breast looks slightly bottomed out and the left side looks more appropriately positioned with the implant centered behind the nipple.

Given that your left side is not dropping with vigorous massage it suggests that you might be developing capsular contracture and massage will not help. You can continue with the massage to see if there is improvement and will need to wait up to six months before deciding if any surgical correction is indicated. 

It is important to recognize that photographs provide limited information so any recommendations or advice will be qualified. It appears from your photo that you fall into a borderline situation. You could probably "get away" with just an implant, but your breasts would be positioned low on your chest wall and you would not have nice upper pole fullness or cleavage. 

Understandably most patients would prefer to avoid the additional scars that are associated with a lift, but the alternative of a low positioned breast may not be very satisfactory outcome either. So you need to think very carefully about what you are trying to achieve. I personally think that you would get the best long term result with a modest size implant and a vertical or lollipop type of lift.