David L. Mobley, MD, FACS

You appear to have Grade II ptosis which is our fancy way of saying borderline drooping.  With moderately large implants and a dual-plane technique you should get a good result using high profile silicone or extra-high profile silicone gel implants.  The incisions could either be inframammary or periareolar.  That's the good news, and for someone who wants to avoid a lift and "doesn't mind" placement being a little low, it usually works out fine.  Contrary to what many of the other doctors have said, I do not think you will be able to completely correct your flat upper pole, since the implants will sit relatively low.  This is not necessarily bad if you are aware and okay with that appearance.  On the other hand if you truly want excellent correction of the upper pole and implants that don't sit relatively low, I would consider a breast lift.  You should make certain to observe the difference on Vectra 3D imaging which can show the changes with specific implant styles and sizes on a three dimensional image of your chest.  It's a great way to help make this difficult decision.

Considering you have a DD-cup breast size with a 350 mL overfilled implant you must have medium sized breasts baseline.  You have two very good options for obtaining your goal of a less droopy C-cup breast.Option 1: Deflate your current 350 mL overfilled saline implants in the office under local anesthesia then allow the skin to contract for 3-4 weeks (Simple procedure where using local anesthesia you poke a small needle hold in the implant and repeatedly draw out fluid until the implant is deflated).  Follow this with and implant replacement and tightening of the pocket (capsulorrhaphy) using implants in that are 100-150 mL smaller.  Since your skin is loose I would strongly consider changing to cohesive gel silicone implants (Allergan Natrelle Inspira Style SRF, SSF or SCF) which help decrease the chance of ripples.   With the contracted breast skin a breast lift can often be avoided.  If necessary, I reinforce the pocket with GalaForm Mesh.  This is an absorbable mesh which is replaced by tissue 3-5 times stronger and helps thicken the typical pocket.Option 2:  Remove the implants and replace them immediately with cohesive silicone gel implant in the same plane along with a periareolar mastopexy or vertical mastopexy to remove the loose skin.  This allows complete control of breast size and shape since the size and shape of the implant and skin envelope are all within the surgeons grasp.  In addition, Galaflex Mesh (absorbable reinforcement mesh) can be used to reinforce the breast lift.  While this approach gives the best shape overall and the most dramatic breast lift, it does result in additional scars which are usually thin lines which are not very noticeable.

I ask patients to stop alcohol "a few" days before surgery.  I avoid suggesting a specific number of days before because social activities do happen and it doesn't have much effect on your surgery anyway.  Having a couple of drinks 3 days before your breast augmentation will not effect your outcome.  On the other hand, I would suggest avoiding alcohol within 48 hours of surgery so you are maximally hydrated and feeling your best.Good Luck with your breast augmentation!

There are four points in the healing process that are important:1.  Incision Sealed at 24-48 hours - The incision is sealed and it is safe to shower.  2.  Incision Healed at 1 week - If sutures are use, they can be removed.  Okay to begin breast massage.  If there is no redness or drainage the incision is highly likely to heal without any problems and is extremely unlikely to reopen.3.  Ready for exercise at 3 weeks - At three weeks one can restart exercise except reaching very high, hanging from a barbell, or heavy upper body lifting 4.  Ready for anything 4-6 weeks - The incision has gained strength and can withstand heavy exercise and any activity you normally take part in.

Breast Implant Replacement Cost is affected by the following:1. Drooping or Sagging of Breasts:  Often with drooping or sagging the cost is higher because of the need for a breast lift or capsulorrhaphy (tightening of the breast pocket)2. Hardening of Previous Implants:  The cost may be higher because of the need for capsulectomy (removal of the hard capsule around the old implants).3. Malposition of the Previous Implants:  Capsulectomy and/or placement of  a supporting mesh or dermal matrix may be needed to improve the implant position4. Desire to Increase Breast Implant Size:  Since a larger pocket is needed capsulotomy is needed which will increase the cost5.  Rippling, Visibility of the Implant, or Thinning of the Implant Pocket:  Adding Galaflex support mesh or Acellular Dermal Matrix (ADM) to thicken pocket and improve decrease visibility may be necessary.  In addition, a using a cohesive gel breast implant will help alleviate this problem.  These implants are more expensive since they are newer.6. Implant Choice:  A large variety of increasingly cohesive gel implants and implants of various shapes and projections are now available.  The newer more advanced cohesive gel implants improve results but also drive up the cost of replacement.7.  If you only need removal of the old implants and replacement in the same plane without modification of the pocket, a breast lift or support mesh then the cost is less Considering all of the above factors I believe it is well worth the time, effort and cost to see a board certified plastic surgeon who will examine you and create a thorough plan for you implant replacement.  Based on this plan the surgeon or his coordinator will discuss the cost in great detail  Indicating expected cost by phone is very inaccurate because of the above factors.  Good luck with your replacement surgery

All breast augmentation patients should wear a post-surgical bra to help maintain breast position both during the day and while sleeping for the first 6 - 8 weeks.  After one week of strict back sleeping (most of the time) I allow patients to get more comfortable and begin shifting to the one side or the other but still mostly on their backs until 3-4 weeks after surgery.  At that point any sleeping position except on your stomach is okay.  A good nights sleep during the recovery period is very important mentally and physically.  Using this schedule I believe implants properly placed during the surgery and supported early on by a post-surgical bra are unlikely to be influenced by sleeping position.  After 2 months the natural capsule has formed around the breasts and I allow patients to sleep in any position without a bra.    

You have malposition of the Left breast implant and a thin pocket medially, both of which are probably related to release of the pectoralis muscle from its sternal attachments.   In the past correction of this problem would be very difficult.  Now with the use of Galaflex Mesh to reinforce the medial pocket and add thickness to this area both problems can be greatly improved and possibly completely corrected.  Galaflex mesh is made from an absorbable natural product called P4HB (Poly-4-Hydroxybutyrate) which is extruded into an absorbable mesh.  Unlike the mesh you hear about on late night TV, this mesh gradually goes away, but leaves healthy collagen 3-5 times stronger than the original tissue.   The manufacturer describes it as a "transient scaffold" used to elevate, support, repair and reinforce.  It is the ideal implant because it is biologically derived, strong, 3-dimensional, monofilament and bioresorbable.  If that seems a bit complicated, I can summarize by saying it's great for helping to correct both implant malposition and thinning of the pocket. 

Returning to work one week after breast enlargement should definitely be possible.  In fact, you should be well on your way to complete recovery from a standpoint of discomfort, swelling, and healing of your incision.  Most of my patients are off any pain medication by 48 -72 hours after surgery.  I allow patients to drive after 4 days.  Clothing choice will be important when you first return to work.  After one week the implants may still sit slightly high and be more firm than they will be once complete healing has occurred.  While the difference will be obvious in a bathing suit or tight fitting clothing it will probably not be as noticeable in regular fitting clothing.   Finally, it is important to work together with your board certified plastic surgeon and choose breast implants sized to fit your chest wall well.   This will give you a natural appearance that looks fuller and more voluptuous, but does not look obviously like breast implants.  I tell patients they should appear to have full breasts for someone with their proportions, but people will think you were just "born lucky" as far as breast size.   In summary, it should be possible to return to work one week after breast augmentation and maintain your privacy.

The Base Width and Desired Projection are most important when choosing an implant and should be part of every thorough breast augmentation consultation:1.  Base Width of Your Breast - The most important measurement in determining which implant will fit your chest wall well is the base width.  This is the measurement of where the breast starts medially near the cleavage to where it ends laterally near the underarm.  It must be measured at the chest wall with a caliper in order to exclude the thickness of the breast.  This number varies from 10 - 13.5 cm depending on whether you have a thin chest or wider chest.  Each implant has a diameter which allows the doctor to determine if they will fit your chest base with.  By comparing the diameter to the base with the doctor can tell you which implants will fit your well.  There are usually several implant sizes that will fit within your base width2.  Desired Projection - Think of this as how full or voluptuous you would like your breasts to be.  Higher profile implants project more and appear more voluptuous.  Moderate profile implants project less and appear less voluptuous.  Remember that you as the patient must be part of this decision since only you know exactly what you want.  I also commonly use two other methods to help women decide which implant is best for them:1.  Trying on implant sizers with a bra and T-shirt in the office - this is one method to help determine size and shape.  While it is less exact it does give patients a "real world" how much enlargement a particular breast implant would provide and helps them determine moderate vs. high profile.2.  Vectra-3D Imaging - using a special 3 - dimensional camera system a 3-dimensional image of your torso and breasts is made.  The computer then allows me to show you a three dimensional image how it would look after a specific implant size, style and shape is implanted literally side by side with your natural breast.  There is nothing like seeing your own breasts enlarged in 3-dimensions to help in making a decision on  which shape and size you want.Using the above system I have had great success in helping women choose the best Style, Size and Projection of Breast Implant which fits both their chest well and fits their desire for projection and voluptuousness and fullness.  Also remember that during your consultation you should be an active part of the decision.  Finally, seek the advice of a board certified plastic surgeon when making this important decision.  There are many other doctors now "pretending" to be plastic surgeons so buyer beware.

Early after breast augmentation it is quite common for the breasts to look and feel different because of slight differences in position, healing, swelling or muscle spasm.  Fortunately at 3 weeks there is no reason to be overly concerned.  I commonly ask patients with smooth implants to begin gentle massage after one week (not applicable to textured implants) to help with discomfort and improve implant position.  Over about 2 months asymmetry and firmness usually goes away on its own.   If one or both breasts are still firm at 2 months, I will consider starting a patient on Singulair which is a medication (usually used for asthma) which may help prevent or correct capsular contracture (hardening of the implants due to thickening of the scar around the one or both implants).  If one or both implants are sitting high in the pocket, an upper pole bandeau (elastic band) can be worn to help gently and continuously push the implants down into the lower part of the pocket. Often by 6 months the implants are soft, mobile and well positioned.   Slight differences in the Right and Left breast are common and often not visible to anyone but the patient and doctor.   It is best to wait a full 6 months before considering any revision surgery and seek the advice of your board certified surgeon.