10 months post op revision, flat spot on right breast and no roundness to the bottom of the breast. Advice? (photos)

Good morning!You have a little scar tissue in the capsule of your lower pole, which makes it flat, makes the breast not quite as soft as the other side, and prevents the implant from filling out your lower pole. At this point if you were my patient I would be having you massage three times daily and take Singulair and Vitamin E, but in all likelihood surgical removal of that part of the thickened, scarred capsule will be necessary for correction.

Hello,Periareolar incisions lead to scarring inside the breast tissue, especially after multiple surgeries. This scarring can lead to a variety of contour deformities due to either tethering or tissue atrophy. In addition, performing breast implant surgery through this incision puts your implant at high risk for bacterial exposure, biofilm formation, and subsequent capsular contracture. Your photos may be deceiving, but it appears that the breast that has the contour defect is also sitting higher, suggesting capsular contracture. You will need to be evaluated to determine an accurate diagnosis and treatment plan, which should not include any further surgery through your nipple-areolar complex; any further surgery to treat the implant or it's surrounding capsule should be through an inframammary incision.  

Would be utmost importance knowing the reason for the capsulorrhaphy you got, symmastia? side boob? bottoming out? combination of the former? In any case, a multipoint capsulorrhapy is the most difficult technique in breast revision surgery, parallels some of the difficult rhinoplasties, as an example, and not often you "nail" the result.IMHO your surgeon did his best, and he is to be commended for this, but:-the implants are set too high, because the submammary crease was not predictively placed considering the implants' dimensions-the implants, themselves, are oversized in width and height and exceed the limits of your anatomy-it is not visible in the pics but I know you suffer dynamic animation flex deformity and dynamic double bubble, because of the pectoralis muscle was not fully freed from your mammary skin (this is the cause of the sunken area you mention); had the implants been placed in the subfascial plane (which I use and recommend), this animation and the sunken are would have been gone-round implants? they are not bad but quite outdated and unwanted by patients, I still use them but 95% of my patients opt for anatomical ones without any hesitation or expressly prompt me to use themIn spite your surgeon did a great thing for you improving your result, I think there are great chances of a successful new revision to optimize your result.Seek the advice and hands of a serious professional who offers to you a time-consuming and expensive procedure; stay far from minimally invassive snake-charming procedures.
Difficulty 8 out of 10 in revision mammoplasties, surgical time about 4 hours (in expert hands, could be even longer).
See the link below to find few cases of my own practice very similar to yours which I had the opportunity to operate successfully on, sharing a lot of common features with the technical problem you have posted.
If you wish better grounded opinion well lit, focused and standard images have to be assessed: frontal, both lateral and both oblique views, also contracting the pectoralis.
Feel free to request any additional information from me.

Dear jmnelson5,
breast revision surgery is the most difficult plastic surgery procedure performed. Botched breast surgery alters normal tissue planes and laxity, the ability of breasts to heal properly, and leaves scar tissue that dramatically affects the level of difficulty of the corrective surgery.Many patients come in to correct poor outcomes from their initial surgeries. The most common problems are due to implant malposition, bottoming out of the implant, poor scarring, and incorrect implant size.While the type of revision required will depend on the result of the previous surgery and the desired result of the patient, some revisions involve extensive pocket repair that may or may not need specialized external bras.If you are considering breast surgery revision, you should speak with a board certified plastic surgeon and have yourself properly assessed. Only after a thorough examination you will get more information and recommendations. Also, you have to make sure that your surgeon understands your breast augmentation goals.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

The flattened appearance may improve but after 10 months I would expect you to see some sign of improvement.  If indeed this breast is not as soft as the other breast you may have developed some capsular contracture.  Mild or early capsular sometimes can be managed without surgery.  I would recommend follow up with your surgeon.

Hi and thank you for the question. Without seeing the operative report or doing an exam I can only speculate. It looks like you had your surgery done through an incision in the areaolas. Sometimes this approach can lead to thinning of soft tissue in the lower part of the breast. If you can feel the implant more in that area than on either side of the depression that may be the issue. It could possibly be related to scar tissue/capsule formation. I would suggest going back to the surgeon now that more time has passed and have anther evaluation. If you don't get an answer you are satisfied with you can always get a second opinion from another board certified plastic surgeon in the area. 
Dr West