Bottoming out or capsular contracture after revision?

Question

105lbs 5"5'. First BA in April of 07' I had elected to go with 350cc saline through the belly button, the results were beautiful for about 8 months when I noticed hardening of the right breast.It was obvious that I had a capsulor contractor. After the second surgery in April 09 We replaced both implants with cohesive gel silicon 500cc with capsulectomy done on the right breast. Then in December 09' had to revise the left breast that had bottomed out. Now 4 months later im not sure if it is bottoming out again or another capsuler contractor or both!

J. Timothy Katzen, MD, FACS · Answer

I am sorry you're having so much difficulty with your breast implants. This is not typical for breast augmentation. I believe the correct sequence of procedures was done, in that, during your second procedure the implants were changed to silicone and placed in a submuscular position.
	Capsular contracture is not uncommon after saline breast augmentation with implants placed subglandular (above the muscle).  Compared with saline implants placed above the muscle, breast  implant capsular contracture is less when silicone implants are placed in a submuscular or under the muscle position.
	Based on your pictures I would say you definitely have bottoming out of your left breast implant. To fix this you have several options;  you could either raise  the left breast implant (inframammary) fold or lower the right breast implant (inframammary) fold. Another alternative is to do a little of both.
	Concerning your question regarding capsular contracture, it is difficult to say if you definitely have breast implant capsular contracture. If you have pain in the breast and firmness of the breast, you probably have a Baker Grade 2 or 3 capsular contracture.
	If you were to undergo surgery I would suggest the following. If the both breast hurt,  I would therefore suggest bilateral capsulectomies for bilateral breast capsular contracture. In addition, I would go with a slightly larger implant on both sides and lower the right implant fold and slightly raise the left implant fold. I would continue with silicone implants in a submuscular position. Good luck with your surgery.

Lewis Albert Andres, MD · Answer

Hello! Thank you for your question! Physical examination will determine if you have capsular contracture. The look and feel of hardness surrounding your implant is seen and/or felt. At its worst, you experience pain. It may also cause distortion of your breast. What has caused it will be in question.  Given your photos and description, it may be a recurrent capsular contracture. Your surgeon will likely recommend implant massage and may add the medication Singulair. If these fail, surgical correction may be suggested. It is a matter of surgeon preference as well as what is seen during your procedure that will determine whether or not a complete capsulectomy is performed. If significant capsule formation is seen intraoperatively, a full capule removal may be warranted with a drain in order to completely remove all of the tissue and allow better adherence of your breast back to its normal anatomic position down on your chest wall. Irrigating with certain medications may also be if benefit. If minimal contracture is seen, it may be possible to leave the capsule, or place cuts within the capsule to allow better adherence. It truly is dependent on what is seen with your capsule and the issues that may be causing you to have such a procedure (e.g., contracture from rutptured implant vs pain vs simple pocket adjustment, etc). Without knowing your issues and without an examination, it is difficult to tell you what may be the best thing for you. I tend to favor performing capsulectomies in order to create a fresh pocket, reshape the pocket, allow better shape and adherence of the overlying breast. I would discuss your issues with your plastic surgeon who will assist you in determining the right modality for you. Hope that this helps! Best wishes!

Otto Joseph Placik, MD · Answer

It is difficult to diagnose if the right is contracted but it does appear that your left is too low. I would recommend downsizing with caspsulotomy on right and capsulorrhaphy on left. .

Shahram Salemy, MD, FACS · Answer

It's hard to know if you have capsular contracture on the right side without examining you, but it's possible that you do along with some bottoming out on the left.  If you have had a repeat of the bottoming out on the left side, one option for correction would be to use a product like Strattice to act like an internal sling to help hold the implant in a better position (your surgeon can tell you more about this product).  The down side is that the product is not cheap, but in cases of repeat bottoming out, it is an option to consider.  In terms of the right side, if the implant is in front of the muscle, I would recommend placing a new behind the muscle at this point to reduce the chance of repeat contracture.
I hope that helps and good luck, Dr. S

Gregory Sexton, MD · Answer

Looking at photos without exam it is impossible to tell, but it appears you have a capsular contracture on the right. If so, the right implant should be tight and hard. If not then it might need revision to drop it down a little.

Steven Wallach, MD · Answer

From the photo, and I would have preferred to see your hands down at your side and not lifted, the right one seems tight.

Darryl J. Blinski, MD · Answer

Thanks for posting photos so we can TRY to give you a diagnosis and treatment options. First you must realize an in person examination is much better than an internet examine with photos.
Now I feel the right breast is capsuled and an inferior capsulotomy is a choice. If the right implant is a 500 cc than that is all I would do for this side. Of course I would drain this side.
For the left side, it appears as a bottoming out, kinda of. A side view would help, but with the frontal the view is not to unacceptable. If you like the left than either leave it alone or I could recommend repair the bottoming out via internal sutures or a combination of the mesh (Strattice).
Finally, I would inform you of the risks involved and may need more than one operation. Hope I have given you at least a game plan. 
From MIAMI Dr. B

Sirish Maddali, MD · Answer

This is a difficult problem. As most of the responses have stated, you should definitely decrease the size of the implants at the next (hopefully last) operation. The left inframammary fold should be raised and any capsular contracture that you can feel should be fixed (especially on the right). Good luck.

Kamran Khoobehi, MD · Answer

The inframmamary is too low over the left breast. Your implants are above the muscle. The other issue is the size of the implant. You have too big a implant and you can see the extension of the implant edge in the midline. The diagnosis of the capsular contracture is very hard from the pictures that you have attached. I would recommened that you see your doctor and ask him about this. Your story of implant problems is very common with transumbilical augmentation.

Brooke R. Seckel, MD, FACS (retired) · Answer

?Thank you for your question.  Obviously it is important that you see your plastic surgeon so that you may be examined and a proper diagnosis made.My guess looking at your photograph would be that the right breast is forming a capsule which is constricting the breast and making at higher than your left breast.  You should be able to determine if this is a capsule by simply feeling the breast and feels harder on the right than the left and you likely are getting a capsule.  Again be sure and see your plastic surgeon for an accurate diagnosis

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