Have my breast implants "bottomed out"? What do I do next? (Photo)

Question

I am 20 years old, no kids, or bad medical history. I received a breast lift + implants Back in July 2023. While everything was perfect the first 1-2 months post opp. I was struggling to like them after the implant dropping. I was told I need to proceed with a mesh bra / scar revision. With this being extreme in my opinion I chose to do other consultations on how to proceed. Now i feel like I have a million opinions. I'm just overwhelmed and extremely upset. Any opinions or thoughts truly help. ty

Gary M. Horndeski, MD · Answer

Your implants are too large for your body and are wider than your chest wall. They are too heavy and your skin envelope cannot hold them. At this time, the revision will probably cost as much or more than the original operation. You may want to remove the implants, lift the breasts and then after 6 months place smaller implants totally submuscular.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Gerald Minniti, MD, FACS · Answer

Your implants have dropped out, and your scars are unacceptable. Did you use post-operative tape to support the skin for 2 to 3 months after surgery? Absorbable mesh is the way to go to diminish the risk of a recurrent drop out after a revision surgery. It does not increase the risk of complications when done by a revision expert. In addition to capsulorrhaphy with mesh reinforcement, your capsules and implants need to be re-assessed. I think a lower profile implant that is wider/taller would look more natural.

Paul E. Chasan, MD, FACS · Answer

Thank you for your question. Unfortunately, there is no easy fix. Many years ago, I pioneered a technique specifically for patients like you termed "Reductive Augmentation". This involves an internal bra-capsulorrhaphy, revision of the mastopexy-lift, and excision of the lower pole breast tissue. There appears to have been too much tension on your breast lift scars and these definitely need to be revised. You should be able to have a beautiful appearing breast with this technique. Best wishes to you.

Connie Hiers, MD, FACS · Answer

If they are not behind the muscle, they should be placed there. The inferior pocket can be tightened and lifted, and mesh could be added for better support. Also, you need to go smaller since your tissue is not supporting this size well.

Darryl J. Blinski, MD · Answer

Based on your nicely posted photos, it appears you have a mild of any bottoming effect. Appears you need a larger implant with a inferior mesh added. Best virtual consult with. Cost $15,000.

Jason Pozner, MD · Answer

Seems like I do corrections like yours almost every day. Your tissues are not doing a great job of supporting your implants. Correction involves placing some support - I like Galaflex mesh. And I agree a scar revision would help.

Mats Hagstrom, MD (license on probation) · Answer

This response was dictated. My apologies for potential grammatical errors.
I’m sorry you find yourself in the situation. You are in regarding your breast surgery outcome.
To simplify things I generally like to break down situations into workable variables.
For breast augmentation there are generally three variables that determine the outcome.
The first variable is the patient candidacy for the procedure.
To determine your candidacy for breast augmentation that we really need to see proper before and after pictures. Your candidacy for breast augmentation may have been inherently limited.
Based on the pictures you’ve included, it looks like your breast were highly divergent.
Variables that lower someone’s candidacy include breast asymmetry, breasts sitting wide on the chest wall, breast divergence, breast ptosis and other variables.
If you don’t have before and after pictures and ask your surgeon to forward the pictures they took.
 Always include proper before and after pictures if you want us to have a good understanding of what’s going on with you currently.
If you do contact your provider, then you may as well ask them to forward your medical record, including your operative report, which you should always bring along for a second opinion consultation.
 The second variable that determines the outcome of breast augmentation surgery is the choice of implants in regards to size shape, and type.
Generally, speaking working with excessively large implants will increase a chance of complications, undesirable side effects, and the need for having revision surgery.
Patients should remain cautious in regards to their enthusiasm for having excessively large breasts.
Patience and surgeons should work with the patient natural breast diameter and try not to violate the breast periphery in any significant way.
Doing so leads to problems like implants bottom out. 
The third valuable is the surgeons ability to place the implants in the correct anatomic location.
I think this is the variable that went wrong in your case.
Your surgeon did not leave sufficient amounts of pectoralis muscle tissue, and did not maintain the integrity of the IMF or inframammory fold.
In doing so it allowed gravity and the contraction of your pectoralis muscle to push the implant downwards, creating a “bottomed out” outcome.
Based on the shape of your breast, it also looks like you may be developing capsular contractions.
Correcting bottomed out implants is complex and is something that should only be attempted by surgeons who have a proven track record with this condition.
Closing the lower part of the pocket to correct bottomed out, implants is usually done placing permanent sutures which can be reinforced with mesh or cadaver dermal products.
It’s important to have a quality assessment to know exactly what the problem is because this determines the correct procedure for revision surgery.
Correcting the bottom doubt implants I think is a given.
If you have caps or contractions, then most likely you will also need a complete capsulectomy on both sides.
It may be helpful to know that capsulectomy surgery is generally covered by medical insurance.
Switching to more modest or conservative implants(smaller) may also help deliver a long-term quality outcome.
Unfortunately, your choice of providers to start with was not ideal.
The two biggest mistakes I see patients make when considering cosmetic surgery are the following.
First is having only one consultation and then scheduling surgery.
By not having multiple consultations patients more or less eliminate the ability to choose the better provider.
Believing you can properly select plastic surgeons using your computer or cell phone is not true.
The second mistake patients make is assuming that somebody who is board-certified in plastic surgery with several years of experience, and overall good reviews has mastered most plastic surgical procedures.
Being board-certified in plastic surgery means your board certified, but that has a little to do with competence.
Board certification means someone was able to pass two examinations.
To find the best provider a generally recommend patients consider the following.
Start by making a list of plastic surgeons in your area who seem to have extensive experience with the procedure you’re interested in.
Next make an in person consultation appointment with each of those providers.
Bring pictures of your body, taking the same way plastic surgeons take before and after pictures and use those pictures as reference during the consultation.
Do not go by memory of what your body looks like.
During each consultation, ask each provider to open up their portfolio and show you their entire collection of before, and after pictures of previous patients, who had similar body characteristics to your own.
Being shown a handful of pre-selected images, representing only the best results of a providers career may be insufficient to get a clear understanding of what average results look like in the hands of each provider, would your results are likely to look like or how many of these procedures they have actually done.
 in my opinion, and experienced plastic surgeon should have no difficulty showing you the before and after pictures of at least 50 previous patients.
Highly experienced surgeons will in fact have access to hundreds or preferably thousands of before and after pictures for commonly performed procedures.
Ask each provider with the most common reason for revision surgery is.
Ask them what the revision rate is and what their revision policy is.
For breast augmentation surgery you want to be on the lookout for providers who end up doing Revisions for bottomed out implants on a regular basis.
All plastic surgeons have revision rates.
Anyone who claims to have a very low revision rates should probably be avoided.
Typical revision rates for plastic surgery procedures is about 10%.
Do not schedule surgery until you’ve completed all your consultations.
There’s no correct number of consultations needed to find the right provider.
A lot depends on luck, and the complexity of the procedure being considered.
For your current situation you may need to schedule more consultation rather than less.
Each provider should be able to clearly Differentiate what the underlying ideology or problem is and explain that to you clearly.
Their surgical solution should be aimed at treating the underlying problem directly with proof of having done similar procedures successfully multiple times.
If you’re having a hard time, finding plastic surgeons, who seem confident at differentiating the problem and coming up with a solid solution with proper evidence of having done this previously and consider looking up plastic surgeons, who do most of the breast reconstruction in your area.
Look for plastic surgeons, who have at least one decade of experience preferably two decades.
Look for those who have very busy breast practices with overall goodratings and reviews.
Having excessive number of reviews does not correlate with quality surgery.
Don’t underestimate providers who don’t have many reviews.
Self promotion skills are generally inversely proportionate with surgical skill. 
Recognize that medical insurance may cover some of the cost of potential revision surgery if you qualify for a medically indicated procedure such as capsulectomy.
This can go along way at ameliorating the cost of having secondary surgery. 
The compensation for medical insurance for plastic surgeons is going to be minimal, but if you can get insurance to cover the operating room and anesthesia fees, then it may serve as a great cost saving for you even if the plastic surgeon charges for their work.

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