Touch up for augmentation + mastopexy
There is some asymmetry which is not uncommon after combining implants and a lift especially with pre-existing asymmetry. Revising the lower part of the lift on the side with some bottoming out will help, and fat grafting can add some fullness to the upper pole. The nipple position looks appropriate.
Saggy breasts following implants
Achieving "perky" breasts isn't always as simple as placing implants. I suggest considering fat grafting to augment the parts of the breast that the implant doesn't "reach".
Aug/Pexy after massive weight loss
Thank you for your question. I would start by telling you that even you hadn't lost 140 pounds you would never have had "cute perky boobs" by lifting your breasts and putting in 500 cc smooth round implants. Your expectations were way out of line with what could be accomplished given the degree of sagging, volume loss and loss of skin elasticity. Your breasts were not symmetrical to begin with and there is no way they were ever going to be symmetrical. Given your preop appearance it looks like your surgeon got a pretty good result with what he was given to work with. If you feel like they are too big then your surgeon can put in smaller implants and revise your lift to tighten them up but understand that gravity and lax skin are not on your side so your breasts will always tend to head south no matter what. Obviously the bigger (heavier) the implant the more this is the case. On patients like yourself I prefer to use textured surface implants
under the muscle in the hope that they will stick in place and give the
best chance for long term upper pole fullness and not shift to the side
when you lie down. I advise my patients that they may be coming back
for a revision of their lifts sooner than they would like and this is
going to be dependent on the laxity and amount of their own breast skin
and tissue. If your surgeon is experienced and is certified by The American Board of Plastic Surgery then he should have the skills to get you closer to where you want to be but you need to modify your expectations and get the word "perky" out of your head.