I am 3 years post-op (300cc Mentor textured silicon sub-glandular). I think I'm bottoming out and there is some rippling. My PS says he would like to do a revise, with an internal bra and go sub-muscular. My question is: does this look awful and is it worth a revise? I am concerned about the scarring and the odds of it happening again. If I do, I want to keep the same size (at least), so how much more cc's should I go to make up for the sub-muscular placement?
Bottoming Out 3 Years Post-BA, Worth The Revision?
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Doctor Answers 17
What to do about bottoming out
i can't really tell from the photo whether your rippling is in the upper half of your breast or not. Is it just ripples below? Certainly changing over to beneath the muscle would help rippling in the upper inner or upper outer portions of the breast, but if this is not a problem when your breast is better supported you may just need an operation to tighten the lower capule. This would give your implants better support and is a quick and simple procedure. What does your breast look like when you press upward along the infra-mammary fold? Does it make everything look fine? If so you might get away with the more simple procedure. Good luck.
Rippling and bottoming out, worth the scars for revision?
An inframammary scar could be used for surgery in a case like yours.
The problems to be addressed are what I would call very mild bottoming out, and rippling.
Your implants are textured and above the muscle. With thin skin, rippling is common with these implants because they stick to the skin, pull it in, giving traction rippling. Very little soft tissue thickness aggravates the problem.
Possible solutions, my preferences, are re-augmentation with smooth gel implants (much less visible wrinkling with gel vs. saline),and placement partially under the muscle.
Instead of a mastopexy pattern scar using the dermis as an internal bra, I would either do a capsular repair to support the implant and treat the mild bottoming out, or better, add accelular dermal matrix, such as Alloderm or Strattice to both reconstruct the inframammary fold internally as well as put a nice layer of support and soft tissue over the implant between the pectoralis muscle and the inframammary fold.Then the scar would be short.
Trade-offs: acellular dermal matrix is expensive, probably adding 3,000 to the cost, but no long scar, which is a plus.
Bottoming out of implants with rippling can be improved upon with surgery.
If you are happy with the current appearance of your breasts then don't have any additional surgery. If you don't like the appearance of the bottoming out of the implants then it can be corrected just as your surgeon described. Placing the implant beneath the muscle will help to pad and camouflage the rippling that you describe. This will not make you look smaller. This will likely give a pretty appearance to the top of the breast with a nice slope. I would recommend placing a biologic membrane as an internal bra for two reasons. This will help with support of your implant and decrease the liklihood of recurrent bottoming out. Also, the membrane sheet can be secured to the edge of the muscle and help hold the muscle in the proper position and prevent the muscle from riding high on top of your implant. You are correct in that the implant can again bottom out. The chance of this occurring increases with increasing heaviness of the implant and lack of wearing of bra for support of your breast. The genetics of your skin and tissue also plays a role.
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Need for post-augmentation revision?
Are things stable now, or are they still changing? Are you okay with the way you look now?
A revision should open the medial pockets to improve the cleavage area. Inferior support with pocket plication or placement of a biologic membrane will raise the implants to a better position. You size looks good for your frame.
Fix a Bottoming Out of Implants
I think you can stay with the same size implants, just covering the upper part of the implant with the muscle. An internal suture capsulorrhaphy should work well to move the implants both up and towards the center. I have not found the very expensive allograft internal support necessary with smaller implants such as yours. I would also advise you to consider smooth implants. The textured ones always seem to ripple more and no longer provide the benefits that texturing did 20 years ago with the old silicone product.
Follow your Board Certified Plastic Surgeon advice and they will lead you to the bets options. Rippling with silicone is rare, but can occur.
Revisional breast implant surgery
Most of the answers to your questions are in the answers given so far. In these situations it is helpful to break down the questions into separate issues and see how they would be addressed.
You don't have true "bottoming out". All the problems are related to thin tissue coverage over textured surface, subglandular implants. The rippling effect can be addressed by changing to smooth surface, round, gel implants. The visibility and contours of the implant would be corrected by changing to a subpectoral position of the implant. Submuscular implants will look smaller (and more natural) so a somewhat larger volume implant would be needed to look about the same size. Coverage over the lower pole of the implant could be improved by an acellular matrix graft but this is a rather complex and expensive solution. The simplest would be to take out the existing implants and replace them in the same subglandular position with slightly wider/larger, smooth surface, gel implants. All these options would be best done through an inframmary crease incision and control of the inframammary crease level.
Fixing Bottoming out worth the revision
There are several ways to revise your breasts to reduce rippling and correct the bottoming out. If you like your size, I would stay in that cc range and switch to smooth gel. It is a relatively straightforward procedure and recovery should be easy with most options. I don't think you necessarily need to move to a submuscular location. Your surgeon will have the best advice knowing the specifics of your history and examination. It is worth it if it is bothering you, although any procedure does have some risk.
Bottoming out may be treated with pocket change to subpectoral
From your photographs, you do appear to have bottoming out. Generally, changing from the subglandular to the subpectoral plane will allow a new pocket to be constructed with the implants in higher position. If you start with 300cc implants and want the same approximate size, a 375 cc implant would likely help. I don't think acellular dermal matrix is necessary in most cases where creating a new submuscular pocket is possible. Revisions are always complex, so be sure you do your discuss this thoroughly with your surgeon and find a surgeon who is comfortable with breast revision surgery. I hope this helps.
Revisionary Breast Surgery
The need for revisionary surgery often times depends on how much the imperfections affect the patient. Based on your pictures, without the benefit of a physical exam, I agree that a sub-muscular re-augmentation along with capsulorrhaphy inferiorly is the operation that is most likely to give you the best long term result. When changing the implant position from the sub glandular to be some muscular position, sometimes skin excision (mastopexy) may also be necessary.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.