Caroline Glicksman, MD

Thank you for your question. Breast implant revisions are extremely common, and many patients with old saline or gel implants are now opting to remove them completely. 

A few points you should consider:

First, as you have decided that you no longer want breast implants, the simplest way for you to determine whether of not you will need a lift or not is to simply perform an in office deflation of your saline implants. Saline implants unlike silicone implants can be safely, and painlessly, deflated by a simple office procedure. This means after 14 years, you can see what your breasts actually look like. It also means that you can be part of the decision making process; no more guessing what you may look like after implant removal. You can see exactly what you look like.

Second, after deflation I offer my patients a Vectra 3D simulation to view what you may look like with either a mastopexy (breast lift with options for incision placement) or a mastopexy with another implant. These simulations are very accurate in most cases and provide patients and their significant others with a very realistic view of their potential outcomes. The most important point I am making is that it is 2017 and patients should become an educated participant in their surgical options. You are fortunate that you can do most of this without ever stepping into the OR. You just have to commit to the decision that you want to deflate your implants and see what has happened to your breasts after 14 years. Then you and your surgeon can make safe, long-lasting decisions together. 

 “Congenital deformities of the chest wall and breasts, although rare, are frequently encountered in a plastic surgical practice. Some syndromes have multi-system organ involvement, while other may involve only asymmetries in volume or shape. Patients and their families are reaching out to plastic surgeons often seeking a one-stage procedure to correct their chest wall and breast defects. Pre-operative assessment and comprehensive patient education can now include in highly specific 3D simulations in the office, allowing the patient and surgeon to simulate possible reconstructive options. The availability of shaped highly cohesive breast implants offers a more precise breast augmentation that controls shape as well as volume. Finally, small asymmetries may benefit from fat grafting procedures, either simultaneously or as a staged procedure.”

This first paragraph is taken from my chapter on the treatment of breast and chest wall deformities published in the Clinics of Plastic Surgery, October 2015. You are correct in searching for a board certified plastic surgeon who has a tremendous amount of experience with the correction of breast and chest wall deformities. The decisions made between the patient and the surgeon before surgery will have a very long lasting impact on how “normal” and “natural” your breasts will look for years to come. I suggest selecting a plastic surgeon that specializes in breast augmentation and especially chest wall and breast deformities. 

As far as "stars" in plastic surgery, my mentor, and a leader in this area is Scott Spear, MD., Chevy Chase, MD.  In Toronto, Mitch Brown, MD. Both are great friends, authors, and surgeons.

I would be very upset if one of my patients was contacting Realself to get answers about a possible post-operative complication. All patients should feel free to contact their operating surgeon, and expect to be talked to and seen in a timely fashion. Realself should not be the platform for patients to get opinions or advice about recent surgery. I suggest you call your surgeon and schedule another follow-up appointment. I'm sure they will be glad to help you.

If you are considering liposuction after a large weight loss, remember one thing: liposuction will remove unwanted fat, but will not make a significant change in the amount of excess skin or the quality of the skin. In fact, removing just the fat from your upper abdomen may create even more of a defect with worsening of the appearance of your upper abdomen. The cheapest answer will most likely be the biggest waste of money.

You should research your options very carefully.  Liposuction or non-surgical fat reduction, like CoolSculpting,  will most likely not help with your excess skin, and may actually make you look worse. Based on the images that you provided, an abdominoplasty probably your best option. This surgery can successfully remove excess fat and skin from the abdomen permanently, and is most commonly performed on women after pregnancies or significant weight loss. If you have gone through a gastric bypass or successful weight loss you should take the time to meet with a board certified plastic surgeon that has experience with weight loss patients. (Click the link below to learn more about the differences between liposuction and an abdominoplasty)

I suggest a careful face-to-face consultation to determine if you are a good, and healthy, candidate for this type of procedure. The procedure can take from two to three hours, and patients usually go home the same day.

Large volume weight loss is difficult, living with the excess skin can be even harder. There are safe options for you to achieve the body imagined, but this is not the time to look for a cheap option that you may spend far more to correct in the future.     

While an implant can be placed under the muscle through a peri-areola incision, the real question should be: what are the advantages and dissadvantages of this incision? One advantage is a possibly well hidden scar. This is possible for some skin types, but requires an areola big enough to introduce the silicone implant without damage. For other women, the areola is too small to make an adequate incision, and there may be dimpling or thickening of the scar that can make it quite visible.

The more important issue is the mounting evidence that increased complications can be associated with this incision. The most significant risk is that of bacterial contamination at the time of implant insertion. Bacteria can lead to higher rates of capsular contracture (hardening of the pocket around an implant). The nipple-areola in most women, especially after breast feeding, is colonized with bacteria (mostly Staph and Strep, but other bacteria as well). Pushing a breast implant through this tissue may potentially contaminate the implant. While some surgeons use a funnel or plastic barrier to protect the implant during insertion, not all do because they don't like them or the cost. Secondly, the surgery should be performed precisely and without any bleeding. Your surgeon needs to see exactly where they are at all times to assure this. 

The inframmary scar, when placed perfectly in the crease, allows the surgeon to introduce the implant gently, reduces the risks of pushing an implant through contaminated breast tissue, allows the surgeon to create a very precise, dry pocket. The scar is barely visible in most patients. There are more important questions than "can your surgeon" do something, the question is "should they" based on the scientific evidence.  

There will be obvious changes to your breasts with each pregnancy, but I am not sure why you think a saline implant is your only option. You have already gone through one full term pregnancy and the changes to your breasts may not worsen much more with each additional pregnancy. The changes are most often related to your weight gain and genetics. A well planned and executed breast augmentation between pregnancies may last you ten years or more with either saline or silicone. 

Other than patients seeking a less expensive implant, just a few hundred dollars difference, I do not recommend saline implants for the majority of my patients since 1998. Saline implants can produce more lower pole stretch deformities, have more wrippling and palpability, and offer less options in size and shape than modern silicone gel implants. Further, there is no data to support any generational effect of silicone gel with pregnancy or breast feeding. 

I suggest you request a consultation with an experienced board certified breast augmentation surgeon that can provide you with your up-to-date options in breast augmentation: before, during, and after kids!

Recently at one of our national scientific meetings, plastic surgeons were asked if they could identify a round implant from a shaped highly cohesive implant based on the post-operative photos. The bottom line is that a properly sized round implant in the right patient can look natural and anatomic, and an oversized, incorrectly positioned anatomic implant can look round, high, and fake. Finding a surgeon who knows how to size a patient and perform the operation properly is probably far more important than the exact cc's or implant shape. 

 There is no one right implant for any patient. There are several choices, both round and shaped that will work for your specific dimentions, soft tissue coverage, and desires. What matters most that you find an experienced surgeon who will provide you with a good education on the benefits and risks of each type of implant, demonstrate what you can look like with the Vectra 3D imaging, and perform neat, dry, surgery. You are fortunate that you live in Toronto where there are many very experienced and talented breast augmentation surgeons.

There are a lot of great implants are the market today, and there is no one exact right implant for every patient. What does matter is the following: does the implant fit your base width-an oversized implant can damage the soft tissues, produce more visibility, and is more likely to bottom out over time. Next, what is the implant filled with? A softer round gel implant may give you some volume, but it will not produce shape to the breast. The softer gels, like Inspira, are better for adding volume; shaped highly cohesive gels are probably best for creating shape and correcting asymmetries. Finally, what is your soft tissue coverage- this means do you have enough breast and fatty tissue to cover the breast implant edges and not see or feel the implant. If you are very thin, an implant that is subglandular may be more visible and palpable, if you have a little more coverage, the implant can be placed subglandular without these issues. 

Bottom line, every implant has its pluses and minuses, if you are concerned about your level of activity, go with a subglandular implant, but be aware of the trade-offs of potential visibilty and palpability of the implant under your thin soft tissue. You need to decide what is best for your look and your life-style. Best of luck.

Real Self is a site where board certified physicians attempt to answer questions based on their experience and training. We can help patients with many problems, but much of the conversation is based on the images provided. It appears that you are the same woman who posted 9 days ago using the same images to ask different questions. (How can I fix my messed up boob? 4 months post-op BA) Plastic surgeons pay attention to details.

Several surgeons suggested that you return to your surgeon for a consultation, and also discussed your options for revision or explantation. If you were sized incorrectly, you will need a revision, if you have a malposition, you will need correction. If you want them out, they will most likely not be very different from your pre-operative breasts after only four months. Unfortunately revision breast augmentation is very common, if you do not want to return to your surgeon, seek out a board certified surgeon who will spend time educating you, before they book you for a revision procedure.

•  heyyyy1616 
•  Long Island, NY 
•  9 days ago

"I don't even know where to start. I'm 4 months post op from breast aug and I hate them. One boob is higher than the other and the nipples are asymmetric. Also one boob is bigger than the other I think it went completely wrong. What are your recommendations to fix this?"

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Thank you for reaching out to RS. If this was 20 years ago I could understand you asking for an oversized implant and your surgeon saying "sure". However, it is not 1990, and breast augmentation surgery has evolved. There are several very important reasons why a well-trained plastic surgeon will use bio-dimensional principles to size a breast implant. The most important reason is to prevent damage to the breast tissue, skin, and muscle, and provide patients with a long-lasting breast augmentation.

You are well on your way to becoming a breast implant cripple if you cannot reconcile the gap between your tissues- a narrow (11cm) base width, with your desires to be a certain cup size. While you can certainly ask for an oversized implant, and will probably find a surgeon to perform the procedure, there will be a price to pay, and not just financially. Oversized breast implants may require releasing the pectoralis muscle, or creating a pocket out into the axilla. Implants are far more likely to be visible and palpable through thin skin. With time, the weight of the heavy implant will create stretch deformities and bottoming out. Does this still sound appealing? I suggest that you select a breast augmentation surgeon who can teach you about your anatomy, and breast health. Then you can select the largest size implant that fits your body,makes you happy, and still produces beautiful long-lasting results.