5 months post op BA, I have waterfall affect. I have two options to fix it but not which one to pick. Any suggestion? (photo)

Question

Hello I had my BA 5 months ago (borderline lift. 385 hp, round textured DP) and i now have the waterfall affect. My original surgeon has offered to do a lift at a discounted rate. I saw another surgeon and he has said he can change the implant into a smaller anatomical and place it subfacially. He said that will give me a rounder breast. I am concerned as he said there is a big risk of rippling as my skin is thin. I have not breastfed yet and am worried about having a lift and doing that. Thanks

Martin Jugenburg, MD · Answer

Based on your pre-op photo you required a lift. Many women are borderline and need to weigh the the risks and benefits of additional scars for a better breast shape.

Jed H. Horowitz, MD, FACS · Answer

Breast revision for implants that are high and pseudoptosis there are sevreral options depending on the experience of the surgeon.  Lowering the fold is likely needed.a smaller implant  in a lower and more medial position or anatomic implant are options.i wouldnt do only a lift as this implant appears too high

George Marosan, MD · Answer

Based on your preoperatively photos, you do have breast asymmetry with the breast folds at different level. You also have psedoptosis or sagging of lower pole breast tissue which your surgeon should've removed at the time of your augmentation. I personally would not recommend going to a smaller shaped implant. Don't see the reasoning how this would correct your current situation. I would do a lateral capsulorrhaphy (close down the lateral pocket slightly) and give you more cleavage. If your breasts are soft, I would use your current implants. You will need your implants lowered (they are too high, especially the right one) and might still need the sagging lower pole breast tissue removed. See a board certified plastic surgeon or seek yet another opinion. Good luck.

Scott W. Vann, MD, FACS · Answer

A breast lift would fix the issue, but I do not blame you if you want to avoid the lift at this time. I would discuss all the options with your surgeon. I would probably try to lower your implants and enlarge the pocket in your lower breast by releasing the muscle from the breast tissue as in the duel plane if these are under the muscle, or just lower the implant if it is subglandular. You may likely need a lift at some point in the future. Good luck.

Amy T. Bandy, DO, FACS · Answer

Thank you for your questions and photos.  It appears to me that the implants are sitting too high, and you could benefit from a capsulotomy or capsulectomy and lowering the implants to sit directly behind your breasts.  I don't think the implant exchange to an anatomical implant will make much difference, and going with a smaller implant may help, but you may end up with a wider gap between your breasts.  I  would need to examine you to be sure, but I think lowering the implants would solve your problem.  Good luck!

Stephen J. Ronan, MD, FACS · Answer

You have a difficult problem that I frequently see and treat. Clearly, from your pre-op photo, it is obvious that you needed a lift.Time and time again I see patients that need revisions because they tried to avoid a lift when they needed one in the first place.  If you have drooping, you should get a lift.  Cutting the muscle and sliding a weight down into a droopy breast only accelerates the drooping.  You are adding an unsupported weight to an already droopy breast!  Putting the implant on top of the muscle creates the same problem but even worse (and creates this problem even when there is no drooping to start!).  The result of either of those surgeries (with the intent of avoiding a lift) is an implant that starts half on the chest and half on the abdomen and STARTS with little support for the implant against gravity.  Time and gravity never stop and will not be kind in this situation.I think that putting a smaller (more firm) anatomical implant (with texturing that has more ripples) on top of the muscle is still going to leave you with drooping and make your next revision that much more difficult.  This would actually make your situation worse.You would benefit from having a lollipop lift, adjust of the pockets to make them ore natural appearing and likely a capsulorraphy on the left to improve implant pocket symmetry.  This can be done in a way to preserve most/all of your breast feeding capability.  Smooth round implants will have less rippling, feel softer, appear more natural, be less expensive and have less problems.The moral of the story is that when you have drooping, you should get a lift.  Trying to avoid a necessary lift leads to poor outcomes, unhappy patients and difficult revisional surgeries.  Of course some patients are resistant to having more scar on their breasts from a lift, but the implant should go supported in the right position on the chest, and if the breast is not over it, then it should get lifted to the right position.I hope this helps and would be happy to answer any questions for you.

Curtis Wong, MD · Answer

you must ask yourself which side do you like better.  Once you choose, then the proper procedure can be recommended.  If you like your left lower side, just lower the right implant for a better look.  If you like the fullness of the right side better, then you must have a lift and find a way to elevate the left side as well, which is much more complicated.  But you need to decide on what side you like better before you can proceed from here.

Kamakshi Zeidler, MD · Answer

Many women have dropping of the breasts and seek breast augmentation, not only to increase the size of their breasts, but to help fill out loose tissue to give a lift. Many women are borderline and need to weigh the the risks and benefits of additional scars for a better shape. When it is unclear if a lift is needed, it is best to wait and see how the initial augmentation heals before committing to additional scars. A dual plane technique helps to create a lift effect by releasing the muscle from the breast tissue to allow the nipple to move into a more lifted position, but sometimes it is not enough. When these techniques are not enough, women are left with a waterfall deformity, which describes the appearance of breast tissue falling off of the implant. This deformity is also seen when implants are placed too high on the chest wall. Textured implants in particular are unforgiving because they gently grip the insides of the breast, so if they are too high, it is unlikely that they will settle with more time.The photos you posted show preoperative breast ptosis or drooping and asymmetry, and postoperative result with persistent asymmetry and implants that are wide set and high in comparison to your breast tissue. When considering breast revision, all of these factors should be addresses for optimal results and several consultations with board certified plastic surgeons will help put into perspective what makes the most sense to you.A breast lift could be done to raise your nipples into a more lifted position. This usually requires a lollipop type incision and carries a risk of losing some nipple sensation and interfering with breast feeding down the road. In general, the less that breast tissue is cut through, the lower the risk, and a lift will likely remove skin with little need for cutting into your breast tissue.Switching to an anatomically shaped implant with high projection (of a similar size) will help to provide a more lifted appearance. Anatomically shaped implants are colloquially referred to as "gummy bear implants" because they are made out of a firmer type of silicone and retain their tear drop shape. Care will have to be taken to make sure the implants have a nice snug fit within your body to prevent the implants from rotating in your body. The benefit to an anatomically shaped implant is that more of the volume of the implant is focused in the bottom of the implant so that the bottom of your breast is preferentially lifted. Less volume is on the top of the implant so that it doesn't create a waterfall deformity. A high projection anatomically shaped implant does the best job of lifting drooping breast tissue. Sientra has the highest projecting anatomically shaped implant currently approved by the FDA - and you may consider switching to this round base, extra high projection implant - it comes in sizes 370cc and 425cc.When considering changing the position of implants from under the muscle to over the muscle (in either a subglandular or subfacial position), you should weigh the risks an benefits. The benefits are that it allows the implant to better fill drooping breast tissue and therefore better lift the breast. The downside is that the edges of the implant can be more visible and that there is a higher risk of capsular contracture. An anatomically shaped implant will have the lowest risk of rippling in an over-the-muscle position.

Erik Hoy, MD · Answer

Hello,I'm sorry you have these issues to deal with so soon after your first surgery.  I think your best option is to have another consult or two with plastic surgeons prior to commiting to a revision.  Find a plastic surgeon who is experienced with the techniques of revising these breast deformities after surgery.  I would tend to agree that your implants should be lowered slightly, which would likely help you avoid having to have a lift procedure for the time-being.  I would discourage the recommendation toward a smaller anatomic implant in the subfascial location for several reasons:1. If you have thin breast tissues, which it appears that you do, the implant will be more visible here than in the     subpectoral position you currently have.2. If you had loose breast tissues/ptosis to start with, you'd likely have stretched them more with a high profile,     larger implant.  When this implant is removed, along with any capsulotomies or capsulectomies, your tissues     may be even looser and thinner.  This is a potential setup for a shaped implant to rotate, even if a     subglandular/subfascial pocket is used.  The pocket may be tight initially, but a smaller implant with a less full     upper pole is unlikely to address the lax skin and soft tissues which can increase the risk for a rotation.3. I disagree that a shaped implant will give a rounder breast than a round implant-- anatomical implants tend to     provide a more natural, teardrop-shaped breast.Unfortunately, this is just conjecture unless confirmed by an in-person exam and consultation!  Best wishes,--Erik Hoy, M.D.

Frederic H. Corbin, MD (license restricted) · Answer

Thank you for your question and photos and though an examination is really needed you look like you would benefit from a pocket revision to lower your implants and put them in a dual planeDr Corbin

5 months post op BA, I have waterfall affect. I have two options to fix it but not which one to pick. Any suggestion? (photo)

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