Why is my reconstructed breast smaller and higher? Why is my reconstructed nipple flat and the natural one isn't?

Thank you for your question.
At the outset it is important to realize that an operated breast will likely never look like a natural breast. In general, breasts are not perfectly symmetrical, and these asymmetries may be accentuated or appear to be more pronounced after surgery, particularly if not recognized pre-operatively. Also, the goal of breast reconstruction, which is a process involving a series of operations, is to achieve good symmetry in clothing. While the results can be revised to try and achieve better symmetry understand that perfect symmetry is often not attainable.
Best wishes!

One of the most common reasons for asymmetry after bilateral breast reconstruction (reconstruction to both sides) is the need for radiation therapy to one side. Often the radiated side will sit higher and tighter than the non-radiated side and feel slightly firmer. Fat grafting of the smaller side can sometimes improve asymmetry if there are minor differences. For significant asymmetry, sometimes a balancing breast lift on the side that sits lower will give you better control over achieving symmetry.

There can be a number of reasons why your reconstructed breast is smaller and without knowing your full history (previous radiation? size of your breasts prior to surgery? health of the breast skin after mastectomy? type of mastectomy, etc) I would be guessing. What I can offer are possible solutions. If an implant reconstruction is too small compared to your natural breast, a breast reduction of your right breast may be a solution. During the breast reduction the nipple and areola can be lifted to treat the asymmetry that you described in your nipple positions. Another option would be to enlarge your reconstructed breast by using a larger implant. An implant exchange may have already been attempted during one of your previous surgeries. You could also consider switching to a natural tissue reconstruction, such as a DIEP or PAP flap. In my opinion, when one breast is reconstructed, a tissue flap reconstruction matches the natural breast better than an implant. I hope this helps.