Do I Need a BA Revision? Bottoming Out, Hypertrophic Scars, Muscular Distortion & Asymmetry. (photo)

I am 27, 116 lb, 5'7" & had BA surgery 15 mths ago. Got inframammary subpectoral 260cc silicone implants & went from small B to large C. My questions are: 1. Am I bottoming out? 2. Is the placement of my pockets and implants correct? 3. Do my nipples point excessively upward? 4. Are my scars hypertrophic? 5. Is my muscular distortion excessive? 6. Are my breasts asymmetric? Considering going to a PS for corrective surgery and would appreciate any feedback from all you Pros! Many thanks!!

Doctor Answers 12

Do I Need A Breast Augmentation Revisionary Surgery?

The pictures you present in this posting show the need for a correction of your double bubble (capsularptosis).  This capsulopexy (lifting the capsule which is obviously down too far) can be done by one of several techniques.  I don't believe you have medial displacement of your breast pocket because the medial portion of the pocket is determined by where the pectoralis muscle inserts into the sternum.  Since your implants are  under the muscle, the medial position of the breast and the implant pocket were determined prior to any surgery. 

By following the threads to your previous posting and looking at your pre-operative pictures, your nipples were high, to the outside, and asymmetric pre-operatively.  If you were my patient, I would have explained to you before we started that your nipples would be on the lateral aspect of both breasts unless you used very large implants which would have led to side boobs which many patients don't care for.  My patients in the past, with your type of good cleavage and high and outside placement of nipples who have elected to have breast implants, knew going in that the nipples would not be well placed on the breast mound. 

I am surprised from your pre-operative pictures and the early post-operative pictures that you developed such a high degree of capsularptosis.  With reference to whether your breasts are asymmetric, they were asymmetric pre-operatively, and the implants only exaggerated and did not create the asymmetry.  With reference to your hypertrophic scarring, I think you just have a wide scar.  Everything about your case makes me feel you may have some excessive elasticity to your tissue, that your surgery was basically done correctly judging from your early post-operative pictures, and that the implant-ptosis and widened scar may be your genetics and not the surgeon's overdissection. 

All that being said, your breasts are revisable.  However, I hope your second plastic surgeon takes everything into consideration, or he or she may be caught in the same trap that I believe the first plastic surgeon was caught in if it is indeed your body's genetic predisposition which led to many of your post surgical problems.

Revisionary Surgery Candidate?

Thank you for the question and pictures.

It is clear based on the pictures that you will benefit greatly from revisionary surgery. Your implants  are both inferiorly and medially malpositioned. These problems can be fixed by altering the breast implant capsules internally  using internal sutures (capsuorraphy).

I would suggest in person consultation with a board-certified plastic surgeon well experienced with revisionary breast surgery.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 1,498 reviews

Bottoming out - breast augmentation revision needed

You unfortunately are correct in your appraisal of your post operative results.  Based on your photos, you have significant bottoming out both inferiorly and infra-medially.  This is exacerbating the lateral projection of the nipple/areola, though not the sole cause of it as they likely projected outward prior to the procedure.  In general, the normal distance between the base of the areola and the infra-mammary crease should be between 5-7 cm, depending on body type.  In your case, the distance is now significantly greater than this as the far right photo where you are flexing your pectorals makes clear (re: the crease of your previous inframammary fold above where the implants have now settled).  

I also agree that you are exhibiting distortion from muscular contraction of your pectoralis.  Correction of this would require a combined approach of a superior and superomedial capsulotomy to release the muscular distortion and an inferomedial capsulorrhaphy to bring the implant back to the appropriate level. During this procedure, your surgeon can revise the scars and also, with proper placement of the implants, better center the nipple-areola-complexes within each breast mound.  

I'm sorry that you've had to deal with these unfortunate post-operative problems. Thankfully, they can all be corrected - you just need to find a plastic surgeon with significant experience revising breast augmentation complications.

The link below is to a revision procedure I performed on a patient who presented with IMF and double bubble complications similar to your own. Hope you find it helpful.

William F. DeLuca Jr, MD
Albany Plastic Surgeon
4.9 out of 5 stars 183 reviews

Breast augmentation revisions

Revisions are a difficult question to answer even with good photos as you have. The key is always to identify the problem, what would be the correction, and is that reasonably likely with a revision. 

This is mostly a double-bubble problem and a good example of where going by cc's alone is not useful. One would think that 260 cc's would not be too big and cause distortion problems but it depends on the dimensions of the implant relative to the breast and Dr. Stephenson may be correct that the implants were too big to stay properly behind the breast. The other possibility is overdissection of the pocket to the medial side, loss of control of the inframammary crease level, and inadequate release of the pectoralis muscle out of the lower pole of the breast (dual plane release).

Dr. Haeck has the basic issues identified although I wouldn't put too much faith or hope in anti-scar measures to avoid a similar scar reaction. The main problem in revision is to make sure the implant width fits the horizontal pocket space and if not then use a narrower implant -- the forward profile doesn't matter much for this. The pectoralis muscle needs to be released out of the lower pole of the breast to correct the double-bubble deformity and the inferior pocket/capsule needs to be taken out and the inframammary crease re-established at the proper level (so that the incision is in the crease or nearly so). I would leave the medial border alone at this point as it is quite hard to reduce it and accept the off-axis pointing of the nipple (which was probably at least somewhat there before the procedure). A bit wider lateral pocket can sometimes help. Look for a plastic surgeon who is familiar with dual plane release, basing implant size on width and crease tucks. 

Scott L. Replogle, MD
Boulder Plastic Surgeon
4.0 out of 5 stars 1 review

In Need of Breast Augmentation Revision!

Thank you for the photos.  I believe the root of the problem is that your implants are too big.  There size has cause some bottoming out which can change the position of the nipples.  The large implants require a large pocket and thus the implant is below the native fold and accentuating the free edge of the muscle during animation. The scar quality could be a better but many factors play into that.  You should consult a board certified plastic surgeon to discuss your options for revision.

Dr. ES

Breast Augmentation Revision

I agree completely with Dr. Haeck.  You have a difficult problem and many variables need correction.  Are your implants shaped implants (style 410 or CPG) or round?  As Dr. Haeck has outlined, a revision will require removal of your implants and extensive modification of your pocket and new implants likely.  You should ideally talk to your original surgeon first about your concerns.  Good luck.

Peter A. Lennox, MD
Vancouver Plastic Surgeon
4.8 out of 5 stars 17 reviews

Your breasts need a complete makeover

Yes to all your questions.  Your pocket is too low and your implants are too far to the middle.  This gives the very distorted look you have.  Without examining your breast I cannot tell if you have capsular contracture but if your breasts aren't soft and squishy then this is part of the problem too.

This is not an easy problem to fix and if you change surgeons this could end up costing you more money than you paid for the original surgery.

The easiest part of all of this is removing your old hypertrophic scar.  To fix everything else this needs to come out first to gain access to the pocket and the implant anyway.  After your next surgery you should be using anti scar measures such as taping and gels for months.

It also looks to me like you have high profile implants.  If this is true the next ones should be moderate profile.

It is extremely important that your next surgeon has had lots of experience fixing these types of problems.  Interview as many as you can and ask them very frank questions.  Can they show you pictures of other similar problems they have successfully fixed?  Can they show you in a diagram what is wrong and where they need to modify your pocket? And what size implant and shape would they choose to help make this look more natural?  Oh, and don't forget to bring along your pre-op photos from 15 months ago.  You have the right to demand copies of them from your first surgeon if you didn't take your own!

Phillip C. Haeck, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 37 reviews

Do You Need a Breast Augmentation Revision

Additional #revision surgery may be required. I suggest beginning with an in-person #evaluation with your original surgeon, or, with a board certified plastic surgeon. It is best select a plastic surgeon who is #board-certified and has a great deal of experience with breast #augmentation and the incision type, #implant placement, and implant type. Plastic surgeons who have specialized in breast surgery and cosmetic surgery are suitable to perform your breast augmentation.

Additional elective cosmetic #surgery is a personal choice. Typically, it's best to wait 6 to 12 months depending on the reason for #revision.  Matters such as sagging or drooping  and size change will not improve with time. As with all cosmetic surgery, results will be rewarding if expectations are realistic. Also, most importantly, communication  and asking questions of your surgeon and the staff are key.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 110 reviews

Bottoming out

You have bottoming out which can be a difficult permanent fix. Repairing it may require a capsular sling and a capsulorraphy. This can lead to recurrent bottoming out if the capsule is not thick enough to hold up the implant. Seek consultation with breast revision specialist. 

Stuart A. Linder, MD, FACS
Beverly Hills Plastic Surgeon
4.8 out of 5 stars 42 reviews

Breast implant revision

Yes your implants are too low and the pockes not ideal. This is why your nipple point too high. Your scars are hypertrophic and cam be revised. You need  corrective surgery and closure of the pocket below and new implants with a better base diameter. This is a challange and be sure you see before and after pictures of the board certified plastic surgeon who does this for you. Good Luck!

Gregory T. Lynam, MD
Richmond Plastic Surgeon
4.9 out of 5 stars 59 reviews

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.