Is it time and what are my best options?

The best option for you is explantation using The Bellesoma Method.  The implants are removed, your breast tissue is reshaped creating upper pole fullness, elevated higher on the chest wall and more medial to increase your cleavage.  Vertical scars are avoided, nipple sensation and the ability to breast feed are maintained, if not injured during your previous surgery.  At the same time or later, fat transfers can be performed if additional volume is desired.  Best Wishes,Gary Horndeski, M.D.

After 20 years, deflation and sagging of the saline implants have occurred.  You will want the skin envelope tightened if your opt for a smaller implant. Recommend that you consider gummy bear or silicone implants that feel much more like breast tissue.  Consult with a board certified PS who has performed hundreds of breast augmentations and lifts with favorable patient feedback and numerous before and after photos in his/her website galleries so that measurements can be taken and all of your questions can be answered to ensure that you can reach your ultimate goal.Kenneth Hughes, MD, ABPS Board Certified Plastic SurgeonLos Angeles, CA

Thank you for the question.  I think your implants have held up well over time.  you could consider concerting to a lift with slightly smaller implants.  I would perform the lollipop lift and stick with saline.

Good morning!Sounds like it's revision time- I would recommend a donut mastopexy to lift your nipple position and tighten your skin, the Internal Bra to tighten and lift and support your implant pockets, and new implants with better projection!

Dear LLRD35,
based on your photos, it looks like you will need a revision surgery in order to get good results. You will probably need a breast lift and implant exchange.  My preferred lift is a lollipop lift when a periareolar won't do (ie greater than 2cm lift required). The lollipop technique was created by a Canadian plastic surgeon named Elizabeth Hall-Findley and treats the breast as a three dimensional structure instead of two dimensions (anchor - lift). Most importantly it does not require the horizontal component scars that the anchor-lift requires and breasts appear much more natural, lifted, and less boxy. Lastly, the lift lasts longer because the lollipop doesn't rely on the skin to hold the breast up, its actually breast tissue thats being brought together to support the breast and hence improves longevity. 
If you are considering a surgery, I would suggest you to consult a board-certified plastic surgeon. Only after a thorough examination you will get more information and recommendations.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Thanks for your excellent question- one way or another you can look forward to great results if you do decide to proceed with revision.  It seems that you have a few different things going on and while many of us may comment online here with a photo, let me say that things such as the nature of your skin, the pinch of the tissue overlying the implant, and the relationship of the position of the implant as it corresponds to the shape of your breast are all things that really need to be evaluated during your consultation.  While your photos show your breasts, they don't show your whole torso and this can also be a bit distorting.  You look as though you may have a long breast form meaning that the distance from your shoulder to your breast crease is long when compared to the rest of your body.  In the "wish" photo without clothes, that person has had her breast crease lowered from a shorter breast length to accommodate those larger implants.  (and indeed this was poorly done, as you can see the asymmetric lower pole of the breasts where the right side looks a bit strange as opposed to nicely shapen on the bottom.)  That woman had a "lift" without a lift by overdissecting the breast implant pocket down relative to the nipple in order to rotate the nipple higher.  That likely can not be done with you as your breasts would lie too low using that technique.  To raise your breast tissue and provide a more youthful appearance, you would likely want a lift of some kind and without an in-person exam nobody is going to be able to tell you if a peri-areolar vs a vertical breast lift will be required.  As for your implants, if you are going to have surgery I would agree that removing and replacing them would be a great idea.  Find a plastic surgeon who's before and after photos you like online, and make an appointment to get their opinion about what can be done to achieve your goals.Best wishes, Dr. L

Hello and thank you for your question.  Saline implants tend to rupture or leak about 30% of the time within 10 years.  I think switching to the new highly cohesive silicone gel implants (also called the gummy implants by some) will give you a more durable product that is form stable (maintains its shape over time), lighter, feels better, and is less likely to ripple.  The size and projection you pick can be decided during a consultation based on your goals and measurements. You will need a breast lift to give you the look that you desire, allowing us to excise excess breast tissue and skin that isn't needed and to shape the breast by wrapping the breast and its skin around your chosen implants. The nipple-areola complexes will also be positioned at the same level centered over the dome of each implant in the center of each breast.  This plan will help you to achieve the wish pic goals you desire and the ultimate breast contour.  I hope this helps to answer your questions and I wish you the best of luck.  Please make sure to pick a board certified plastic surgeon with expertise in advanced aesthetic breast surgery techniques, breast revisions, and lifts.Sincerely,Dr. Sean Kelishadi

You would do well with a remove and replace (cane certainly go smaller but with the right implant maintain shape) with a breast lift. Consult only with board-certified plastic surgeons.Dr. Edwards

Yes, based on your description, it is probably time to proceed with revisionary breast surgery. Options will likely include removal/replacement of breast implants or (more likely) removal/replacement of breast implants along with breast lifting surgery. My best advice: select your plastic surgeon very carefully. Make sure that he/she has significant experience achieving the types of outcomes you will be pleased with. Then, communicate your goals carefully, as well.   In our practice, this is best done with the help of goal photographs and computer imaging.  
Working together you will come up with a good plan to achieve your goals. 
Best wishes. 

Sorry for your problem and from the photos it is time for a revision.  So go on some complimentary consultations with experts and compare recommendations after a full examination and discussion of desired results Dr Corbin