Douglas L. Forman, MD, MBA, FACS

At the time of your initial consultation were you able to discuss with your surgeon your goals of having a full breast mound but not creating a breast mound that would be too large for your overall body habitus? This would have been an important step in order to achieve your desired goals. Hopefully not only did you have this conversation, but in the best case scenario you would have been able to try a different sized implants to help determine visually what look you desired. Even board-certified plastic surgeons cannot guarantee final cup sizes but it is helpful if they have a general idea of what size implant you desire, or at least a close approximation in terms of cc's (milliliters).

Going forward, if you feel your breasts are too large for your petite frame then this would entail downsizing to a smaller implant. A smaller implant will create less of an unnatural appearance in the upper breast pole region where you have excess fullness. However, a smaller implant may also yield a droopier breast mound. Downsizing less than 75 mL is typically not recommended as it will not yield much of a noticeable difference . Conversely, downsizing by more than 100 cc or mL may create a situation where you will need a breast lift in order to maintain a perky breast appearance and not feel that you have to wear a bra as this was one of your stated goals. The trade off for a breast lift are the additional scars. I would recommend that you ask your plastic surgeon to place a 375 cc implant in 1 hand and then placed different sized implants in your other hand so you can see the difference in the volume change between various sizes.

Hopefully you find this information helpful and good luck in your discussion with your surgeon.

While it is unusual to develop an early capsular contracture 1 year following breast augmentation, it is not unheard of. There may be many factors that have contributed to your capsular contracture such as if the implants were placed over the muscle or if you had blood remaining in the pocket at the time of the augmentation or if you developed an infection anywhere in your body after surgery. Also, patients have reported developing capsular contractures after undergoing dental procedures with the bacteria that circulate through the body that settle on the implants and initiates the cascade for an eventual capsular contracture. Therefore in our practice, for the first 2 years after breast augmentation, including revisions, we recommend that patients take a dose of oral antibiotics prior to any dental procedure, including cleanings. While there is no good plastic surgery data or literature on this topic this recommendation is similar to the orthopedic literature for patients with knee and hip replacements. Also if patients develop a capsular contracture, Singulair, a prescription asthma medication that blocks inflammation, has been shown anecdotally to at least stop the progression of a capsular contracture and even in some cases reverse it.

With regard to your question about pregnancy creating a more natural appearance, this is unlikely. Most likely your breast will go through some changes with pregnancy and subsequent breast-feeding, if you choose to breastfeed, however I do not see an instance where this would reverse a capsular contracture. Conversely, following breast-feeding the breast typically involutes and your capsular contracture may become more obvious. You already stated that it looks like a ball on your chest and it may then look like a ball that hangs in the bottom of the breast mound if the implant is in front of the muscle. If the implant is behind the muscle then the ball will sit up high on the chest and the breast mound will fall off of the front of the implant and the breast will hang in a dependent fashion.

At this juncture it is recommended that you follow-up with your original board-certified plastic surgeon so they can evaluate where you are now and give you additional information about your implants going forward. Typically patients have implants changed several times over the course of their lifetime and it may be in your best interest to consider this option in the form of an open capsulectomy and implant removal followed by a possible re-augmentation. If you have been happy with saline implants you can stay with that type of an implant or if you had experienced rippling prior to your development of capsular contractures, then you should consider a round smooth silicone gel implant which tends to have less rippling and feel more natural than saline implants.

Typically when patients undergo liposuction they often address 2 or more sites at the same operative procedure. In many instances they may have multiple areas liposuctioned. As an example, a patient who comes in for liposuctioning of the abdomen may also undergo liposuctioning of the mons pubis, back and flanks to create overall improved contouring of the trunk region. Similarly, for the lower extremities patients often treat the outer thighs, inner thighs and knees at the same operative procedure. It is not unusual for patients to also add in submental (neck) liposuctioning at the same time as other areas are being addressed. First and foremost, it is important that the patient is evaluated by a board-certified plastic surgeon before undergoing liposuctioning to determine if this is the optimal procedure to achieve the patient's desired results. In cases where patients will have poor skin quality excisional surgery, such as an abdominoplasty, would yield a better result than liposuctioning alone as the latter could just create looser, empty appearing skin which hangs in a more dependent fashion. When multiple areas are being treated I find the best results are achieved when the patient is under general anesthesia. That way they have a more positive experience and do not experience discomfort, not only from the liposuctioning but also initially from the tumescent fluid which is placed in the tissues in order to provide analgesia as well as vasoconstriction to decrease bleeding, swelling and bruising. If the patient is having multiple areas treated under local analgesia only or with IV sedation then they may experience more discomfort which could limit the surgeons ability to adequately remove the excess adipose tissue. Furthermore, when the patient is under general anesthesia it is easier to move them about during the surgical procedure to obtain optimal results.

Congratulations on taking the first step in your weight loss journey. Following a gastric bypass procedure there may be an initial precipitous drop in your weight. Then the weight loss will slow down and eventually plateau. It is often recommended that patients wait a full year following the gastric bypass or any other bariatric procedure before pursuing plastic surgery procedures. The reason for this is that it typically takes this amount of time for the weight loss to plateau. Occasionally patient's may even gain a little weight (experience a bump in their weight) at one year and then it stabilizes again at 2 or 3 months later. In some instances the weight loss may plateau prematurely because of a hanging pannus that interferes with exercise or other activities that limit further weight loss. In those cases a panniculectomy may be indicated to help further additional weight loss. Then once the target weight is achieved then the patient can undergo aesthetically oriented body contouring procedures. However, this is typically not the case and most patients undergo their body contouring procedures approximately 1 year following the bariatric surgery. It is recommended that you begin to meet with plastic surgeons approximately 10 months following your weight loss surgery in order to not only select the appropriate board certified plastic surgeon but also to get a sense of what procedures you may benefit from as well as the typical postoperative course associated with the desired procedures. In addition, you will also be able to learn what the costs involved with the procedures are. Best of luck!

In planning an abdominoplasty it is important to address any previous scarring. It is common for women that have a C-section scar to have a depression with tissue that overhangs the scar. This creates a shelf-like deformity. Based upon the pictures you admitted, it is important to plan the abdominoplasty incisions appropriately in order to give you the best possible result and to set the scar as low as possible. I typically make a new incision below the previous C-section scar in order to remove the old scar completely. This allows the new scar to be easily hidden under small underwear and bathing suits. Occasionally the distance from the previous bellybutton site to the level of the C-section scar may necessitate a small vertical scar in the central lower abdominal midline from failure to remove the previous umbilical site. This essentially creates a T juncture in the central portion of the abdominoplasty scar. It is usually quite small and easily concealed. A portion of your procedure should entail tightening the abdominal musculature to give you a flatter appearance. It appears that you have excess intra-abdominal or visceral fat that is present. Therefore you will never have a small appearance, but it will be significantly improved if you undergo muscle tightening at the time of the abdominoplasty. I find that patients who undergo a tummy tuck will then lose additional weight postoperatively because of the time and money that they invested in the procedure and the overall desire to have an even better result. The breast reduction can be performed at the same time as the abdominoplasty. Most autoimmune diseases and arthritis should not create a conflict as long as you have medical clearance from your primary care physician prior to undergoing your procedure with a board certified plastic surgeon. If you are taking steroids or aspirin-like medications your plastic surgeon would typically have you taper and stop these prior to surgery but only under the direction of your primary care physician. Your back discomfort may even improve following not only the breast reduction but also tightening of the abdominal wall musculature to give you improved support anteriorly. Good luck with your mommy makeover journey.