Physical exam is necessary to determine the best route to proceed from here, and your surgeon has the benefit of that information, as well as information regarding your pre-op status and what was done at the time of the procedure. You do have asymmetry, with the right implant appearing to be in a position that is too high, with excessive upper pole fullness, and downward tilt to the nipple seen on lateral view. This can occur with capsule contracture, as well as with failure of the implant to settle and position symmetrically for various reasons. You did start with volume asymmetry and asymmetrical degrees of sag, though the starting point fold position symmetry is also key, and cannot be ascertained from these views. If your fold on the right is presently higher than the pre-operative fold was, then lowering is the correct answer, however attempts to further lower a well-defined fold that was present pre-op will lead to a double fold deformity, particularly if the pectoralis muscle origins are also released as part of the surgery. Double fold is seen when there is a difference in the tension of skin of the breast, and the tension of the skin from below the original fold that is recruited into the lower pole of the breast by creating a new lower fold. Another option would be to lower the right as much as possible without double fold, and then tighten the left side further in order to meet halfway regarding the symmetry. That is particularly true if the starting point fold level was lower on the left than on the right If a capsule contracture is the problem, then it should generally be treated with Accolate or Singulair and then addressed once it has matured and stabilized; generally at 6 months or longer. If you do not understand the plan by your surgeon, make sure you are totally clear in that regard. I hope that this helps. Best wishes,
Tom DeWire, MD, FACS
It is likely that you will need a revision to correct the pocket on the higher side. I would wait a full 4-6 months total to see if the right side will drop.
Although your pictures are helpful, it's virtually impossible to make a specific recommendation without first performing a physical examination. Your pictures demonstrate significant breast asymmetry. Your right breast implant is superiorly mal-positioned and your right infra-mammary fold is elevated as well. In contrast, your left inframammary fold is relatively low.
Under these circumstances, it's highly probable that you will require revisional surgery. This will probably require expansion of the inferior breast pocket to lower the position of the implant on that side. It's also possible that an adjustment of the infra-mammary fold on the left for symmetry will be necessary as well.
This type of revision should be delayed for at least six months to allow adequate healing and resolution of inflammation. It's important to realize that revisional surgery can be complicated and unpredictable. For this reason, we prefer performing this type of procedure under general anesthesia.
If you're considering revisional surgery, it's important to maintain close contact with your plastic surgeon. Your surgeon should be able to formulate a treatment plan that addresses your anatomic findings and achieves your aesthetic goals.
Healing will go on for 2-3 months for the early period.
There may be some swelling, bruising, malposition, color differences.
Sensation will be abnormal. Scars will be changing.
Revisions are needed for malposition and asymmetries that dont improve
If you have concerns that something is more
unusual, you should contact your PS to discuss these concerns
Thank you for your question. Of course an in person examination is necessary to provide you with the best answer.
I agree there is a significant concern of double bubble or bottoming out if an attempt is made to lower the right breast.
Looking at your preop photos and your postop photos the left breast was more ptotic or sagging in the beginning and the implant has exaggerated this asymmetry.
My approach might be to lift the lower breast in an attempt to create a closer match with the higher right side. However I would wait at least 6 months before attempting any correction. For more information on correction of asymmetry please read the following link:
Thank you for your question and photos. Yes, it seems like you will need a revision on the right side. The implant is riding high and a revision of the pocket will be needed. I do not perform these procedures under local. Rather, I prefer general anesthesia in the operating room because this is not just a small tweak of a scar. I would wait between 3-6 months at a minimum. The risk of a double bubble is small, no different than with the original operation.
Best of luck.
I agree that the amount of asymmetry is substantial and much greater than before surgery. Lowering the right implant is reasonable, but given that your left breast was lower before surgery, repositioning the left implant slightly higher in addition to lowering the right implant might very well be a better solution. My advice would be to wait a full 6 months to let everything fully settle. Early operations can be less predictable. Procedures done under local anesthesia can easily be done, but it is important that the procedure be done with care: both in terms of full operating room sterility, but also care surgically. If the procedure is being done under local to minimize costs only, it is important that the procedure be treated as a new procedure, and not just a minor tweak. Your surgeon is absolutely right that there is a risk of a double bubble, and therefore it is important that the procedure be done in the most meticulous fashion possible at the optimal time: which why I would recommend waiting a full 6 months.
I would give things another few months before making that decision. Right now, it looks like there is a little discrepancy in volume along with the implant position issue. I would not recommend doing things under local, but that's just my preference. I think people end up trying to get away with things and doing things to save money and it can lead to issues like infection and perhaps not doing all that's necessary due to patient discomfort. I don't think that opening up the lower portion will lead to double bubble either- that is if the muscle is divided correctly.
Usually I would advise to wait at least 3 months after the primary operation. But in this presented case the iatrogenic asymmetry is so obvious I recommend immediate revision surgery. I advise against local anesthesia and I might use fat grafting.
Usually we would wait a bit longer before planning any revision surgery, as the tissues need that time to heal and settle, however, given your preoperative appearance and what things look like now, I think it is appropriate to declare the "handwriting on the wall" at this point. The main question, though, is what should be done now? Your surgeon is the "man on the scene," so he has the best ability to fully examine your breasts and assess things like tissue tone, measurements, and such. I can tell you what I personally see in the images you have shown. I think you had a bit of ptosis on the left breast, and it may have been more than appreciated initially. The right inframammary fold was higher as well. Your left nipple is still lower than the right one, and the left breast tissues are still looser. This allows the implant to "fall" or settle lower on the left. It looks like you may have had a periareolar lift, at least on the left, and you noted that you had a "lift" but didn't specify this any further. In any event, the current situation won't be corrected with adjustment of the breast augmentation alone, and in my opinion, it won't be corrected with simply lowering the right inframammary fold under local anesthesia. It is true that a "double bubble" deformity could result from that maneuver, but done correctly, it should be fine. I agree that it is something that needs to be done, though, because your right implant is too high, not only for the left breast, but for the right nipple and chest wall structures too. My main concern is that you will still have laxity and ptosis in the left breast, and this will lead to persistent asymmetry unless something is done to improve that. I would personally suggest considering some form of lift, if you haven't had that already, and although it may be possible that this can be done with only a periareolar, or "donut" type mastopexy, you might need a more extensive lift like a lollipop or vertical lift to accomplish the goal. This is where the personal evaluation is critical because I can't really examine your breasts to tell. However, given that the breasts were so notably different to begin with, it stands to reason that in order to make them more similar we might have to do notably different procedures on the two breasts. I know we would always prefer to keep the procedures symmetrical and to avoid any unnecessary scars that come with lifting procedures, but sometimes if we are to attain the best results possible we can't avoid that. Additionally, I would think this is something that would be best accomplished under a brief general anesthetic. While it can be performed under local, I think you would be most comfortable, and your surgeon would be most comfortable, if you were asleep, and that is the way to get the best results, not cutting any corners. These are just my own thoughts as I review your images and your story. Again, your surgeon will have the best opportunity to fully evaluate you and formulate the best plan to improve your result. Good luck.