Should I trust my surgeon? He suggested using internal sutures to fix bottoming out

Question

I had gotten a breast augmentation with 450cc implants and a lift back in may. My right implant started bottoming out so I made a follow up appointment with my surgeon. He suggested using the internal sutures to fix this and claimed if this doesn’t work we will then use the mesh instead. It’s worrisome that he seems unsure if the sutures would work. If he felt there is a chance the sutures will not hold would he have recommend just using the mesh immediately?

Gary M. Horndeski, MD · Answer

Your implants are large and weigh 1 lb. each. The weight of your implants is only held up by the skin envelope. Obviously, your skin cannot hold up the implants and that is why you are bottoming out. Internal sutures or mesh will not solve the problem. You may be better off with smaller implants or implant removal, lift and fat transfers.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Connie Hiers, MD, FACS · Answer

Many surgeons do try sutures first if there is enough tissue to work with and the implant is not too large. First, there is less foreign material inside and less risk of a thick capsule forming. Second, it avoids the extra cost of mesh.  He probably has done surgeon long enough to know when mesh is needed initially.

Mats Hagstrom, MD (license on probation) · Answer

This response was written, using Word recognition.
My apologies for potential grammatical errors or the potential rambling nature of the response.
There are a few things to take in the consideration.
Plastic surgeons who are good at breast augmentation should not have implants that bottom out in the first place.
The fact that this happened is a bit of a red flag for your provider.
Regardless the indication for surgery for implants that are bottomed out is a bit different than your initial indication for surgery, which was cosmetic breast enhancement.
 For any plastic surgery procedure you need to confirm that your provider has a skill and experience with the task at hand.
For Your first procedure this meant that your surgeon has skill experience in delivering consistent quality breast augmentation outcomes.
Now it means that your surgeon has skill and experience, in correct implants that have bottomed out. It’s a different condition and a different procedure. 
I recommend you have an honest and straightforward conversation with your provider first asking how often they have patients who develop implants that bottom them out and secondly how many of these revisions they have done. 
This should in fact, have been a question during the initial consultation.
Most patients are probably not aware to even ask this during consultations but asking your surgeon what their most common indication for doing redivision surgery is a good idea. 
 Plastic surgeons that have implants that bottom on a register basis should probably be avoided in the first place, though this is going to be difficult to determine on initial consultation. It helps if you ask. 
The chance of having implants that bottom out go up significantly whenever using excessively large implants.
This is something you should ask yourself now. Are your implants significantly larger than your natural breast diameter?
Correcting this deformity is more difficult when using large implants.
Ask your surgeon how many cases they’ve treated previously and asked them to show you before and after pictures.
If they don’t have before, and after pictures of correcting the deformity, then they probably don’t have sufficient experience to be doing the procedure.
Each time someone has revision surgery increases the chance of needing further surgery with further deterioration of the overall outcome and increased of possible eventual implant failure.
The goal should be to have the least number of operations to develop a long-term stable high-quality outcome.
There is most likely a significant cost advantage with staying with your surgeon.
The key is to get a definitive correction of what is a fairly difficult situation to correct. 
Breast augmentation outcomes are generally based on three variables.
The first is the patient candidacy for the procedure in the first place.
The second is implant selection in regards to size shape and type. Using excessively large implants is highly correlated with this complication.
The third Variable is the surgeons ability to put the implant in the correct and atomic location.
 Implants that bottom out are generally based on a failure of atomic positioning during surgery. This is further increased by the use of excessively large implants so there are two variables that potentially add to this undesirable outcome.
It’s your responsibility to confirm that your provider has skill and experience correcting this breast augmentation complication.
You are no longer vetting your surgeons ability to do quality augmentations, but rather to correct implants that have “bottomed out”.
Vet providers by asking them to open up their portfolio and show you their entire collection of before and after pictures of previous patients who had similar characteristics.z. In this case correcting implants that have bottomed out. 
As in general statement, surgeons, who have implants that bottom out are probably not the correct surgeon to fix the complication.
Good plastic surgeons should understand the importance of not violating the IMF( infra mammary fold) and respect the need for using appropriate size implants or guide their patients to more appropriate implant decisions if the patient is requesting excessively large implants.
Implant choice has a lot to do with this condition, including the success rate of The revision procedure.
If you currently have an excessively large implant than the chance of success with revision decreases substantially.
The condition can be corrected using internal sutures only, but the chance of success is dependent on surgeon skill, and implant selection.
The chance of success is generally increased with the use of mesh, but only with surgeons who have experience doing the procedure.
If mesh can be avoided then that is generally considered better But not if it’s at the cost of needing more surgery. 
To give you quality guidance we really need much better information, which should include a complete set of proper before and after pictures and access to a copy of your previous operative report.
You should recognize that it is your responsibility to vet your provider for their skill incorrect in this outcome.
I usually recommend having a few second opinion in person consultations with other providers in your community in order to find the surgeon, who has most skill and experience with this particular procedure.
For second opinion, consultations come prepared, bringing with you a complete set of proper before and after pictures and copies of your previous operative report.
These are all part of your medical records, which you have a right to obtain by requesting them.
A proper assessment also should include an examination.
Avoid virtual consultations whenever possible and rely instead exclusively on in person consultations.
There’s no correct number of consultations needed to find the right provider. 
The more consultations you scheduled the more likely you are to find the better provider for your needs. 
Patients need to take responsibility understanding that it is there Job to vet providers.
Do this by asking providers to open up their portfolio and show you their entire collection of before and after pictures of previous patients who had similar characteristics.
Maintaining continuity of care is considered ideal but so is finding the right surgeon for your needs.
When in doubt, slow down and schedule more consultations.
Failure to adequately correct this complication can lead to ongoing in need for revision surgery, which can inevitably increase the chance of implant failure with possible long-term breast deformity. 
Do it once and do it right. 
It turns out finding the right plastic surgeon is much more difficult than most people realize.
If you don’t know what plastic surgeon to consult with, then consider finding out who does most of the breast cancer reconstructions in your community.
Plastic surgeons who have extensive experience with breast cancer, reconstruction tend to be fairly good at taking care of complicated breast surgery situation.
Best,
Mats Hagstrom MD

Should I trust my surgeon? He suggested using internal sutures to fix bottoming out

Answers (3)

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