Best Way to Communicate Breast Surgery Expectations?

I had breast lift and implants done in 2006 after massive weight loss. I asked to be a perky full C to a small D. I ended up being a not perky 34DD! The skin still hangs off the implant when I bend over and the breasts seem so wide with no upper fullness. The implants (round saline) drift peripherally from under the muscle slightly while I'm standing. Almost as if the implants themselves were too wide for my ribcage, especially now that he's done the planned central body lift. Should I bring photos of what I'm looking for?

Doctor Answers 13

Yes that would help.

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From your frontal view, I note that the nipples are low, and the breasts are large. I also do a lot of MWL surgery, so I can tell you that one of the big problems is relaxation of tissues after surgery, due to the stretched skin and supporting structures.

I think that a secondary breast lift to raise the nipples and tighten the skin envelope will be needed. From your description of the inplants, you may need the pockets adjusted, and perhaps a smaller inplant.

Bring pictures for both of you to study. Remember however, that this is just a guide, and that we do have limitations of what we can do. You have a lot of breast tissue to work with, so I think you should get a good outcome with proper planning. Obviously, communication is key here.


Breast surgery with implants after massive weight loss

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As Dr. Rand has noted, the elasticity of the skin after massive weight loss is usually greatly diminished. You have relatively large implants in place and have already undergone a lift.

We have found that patients with massive weight loss do best with smaller implants and a lift. That way, the compromised skin is less stressed from a large implant. It seems that your size wishes are smaller than what you currently have, so a redo lift with small implants and capsular reformation may be your best option.

An experienced plastic surgeon is well familiar with these issues and will focus on what can realistically be achieved. Photographs help for discussion purposes of what the patient is trying to achieve, but your skin is not the same as patients in photographs who have never gained and lost a great deal of weight.

Brent Moelleken, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 194 reviews

You may not be able to have what you want

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Please understand that after massive weight gain and loss, your tissue elasticity will never be normal anymore. This colors completely the type of result you can expect. For your type of starting point, you have a perfectly acceptable result with good symmetry. If you wanted to go smaller, you would need smaller implants and a complete re-lift done. The implants will look wider apart because they are smaller and you will settle and relax again because of the elasticity issues. So, while showing your doctor photos would be reasonable, just like showing a hairdresser a hairstyle you like, you might not be able to have the result yourself.

Breast implant sizing

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Thank you for the important question.

Much of the final “look” achieved after breast augmentation surgery  depends on several factors:
1. The initial shape, size (volume of breast tissue), symmetry of the patient's breasts. In general, the better the  preoperative breast appearance the more likely the breast augmentation “look” will be optimal.
2. The experience/skill level of the surgeon is important in determining the final outcome. For example, the accurate and gentle dissection of the breast implant pockets are critical in producing  long-term  well-placed breast implants. I personally think that these 2 factors are more important than any others, including type (saline or silicone)  or model (low/moderate/high profile)  of implant.
3. The type of implant used may  determine the final outcome, especially if the patient does not have significant covering breast or adipose tissue. For example, some surgeons feel that silicone implants have a more natural look and feel than saline implants because silicone gel has a texture that is similar to breast tissue. Each patient differs in the amount of breast tissue that they have.  If a patient has enough breast tissue to cover the implant, the final result will be similar when comparing saline implants versus silicone gel implants.  If a patient has very low body fat and/or very little breast tissue, the silicone gel implants may provide a more "natural" result.
On the other hand, saline implants have some advantages over silicone implants. Silicone implant ruptures are harder to detect. When saline implants rupture, they deflate and the results are seen almost immediately. When silicone implants rupture, the breast often looks and feels the same because the silicone gel may leak into surrounding areas of the breast without a visible difference.  Patients may need an MRI to diagnose a silicone gel rupture.   Saline implants are also less expensive than the silicone gel implants.
Other differences involve how the breast implants are filled. Saline implants are filled after they’re implanted, so saline implants require a smaller incision than prefilled silicone breast implants.
On May 10, 2000, the FDA granted approval of saline-filled breast implants manufactured by Mentor Corporation and McGhan Medical. To date, all other manufacturers’ saline-filled breast implants are considered investigational.
As of 2006, the FDA has approved the use of silicone gel implants manufactured by the Mentor Corporation and Allergan (formerly McGhan) for breast augmentation surgery for patients over the age of 22.
4. The size and model of breast implant used may  make a  significant difference in the final outcome. Therefore, it is very important to communicate your size goals with your surgeon.  In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural” or “C cup” or "fake looking" means different things to different people and therefore prove unhelpful.
Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup  size may also be inaccurate. 
I use  intraoperative sizers and place the patient in the upright position to evaluate breast size. Use of these sizers also allow me to select the breast implant profile (low, moderate, moderate plus, high-profile) that would most likely achieve the patient's goals. The patient's goal pictures are hanging on the wall, and allow for direct comparison.
I have found that this system is very helpful in improving the chances of achieving the patient's goals as consistently as possible.
By the way, the most common regret after this operation, is “I wish I was bigger”.

I hope this helps.

Expectations for a breast lift with implant surgery

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Communication is key when planning this procedure. Be sure that your board-certified plastic surgeon has great deal of experience with the many different techniques that are available for breast implant surgery. A great deal of time should also be spent discussing the ultimate size of the breast and the size of the implant will help you accomplish your goal. Your plastic surgeon should also be able to anticipate the types of scars will be necessary and there lengths

Unhappy with lift and implants

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Remember, that with massive weight loss, the skin does not have the same strength as someone who has not lost so much weight, so realistically this may be impossible to achieve for the long term. On the other hand, a lift alone at this point may improve your result.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Photos are sometimes helpful

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You may have been someone who may have benefitted from a breast lift alone first (because of the amount of breast tissue you have) and then your could decide on an implant size by placing implants into a bra to try to visualize what you might get as a result. It sounds like the pocket around your implants needs to be tightened internally and possibly even a revision of your breast lift. There are a number of options, to include doing nothing, that are available to you.

Dr Edwards

You don't have a bad result, but it can certainly be improved.

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Communicate with your surgeon the same way you are communicating with me. It is clear what you want, and it is reasonable.

I think two things can be done differently, and we see this commonly in breast lifts in New York.

1) You need another lift with implants OVER the muscle. Then the implants wil move with your breasts.

2) You need smaller implants. We use disposable implant SIZERS during surgery to find the right size, BEFORE we open the permanent implants. A sizer costs only $45, and it taks all the guess work out.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Your breasts are still large and behave independent of the implant

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Perky may not fit your body type. Generally perky does not last forever. So be careful what you ask for. There is no way to defy gravity over time.

From your description it sounds as if you still have a significant amount of breast tissue. That is why it "falls off" the implant when you lean over. It is likely that you will best be treated with a repeat lift, a breast reduction and a smaller implant. Really, the only way to get substantial perkiness is to do a very agressive reduction to the point that you eliminated most of the breast tissue and substitute it with a textured implant so that it "velcro's" itself in place and doesn't slide to the sides when you lay down or weigh down the breast when you stand up. This is similar to the type of breast we create when we do a breast reconstruction with an implant. However, most surgeons would not advise that you pursue this course. Clearly, you have large breasts and the purpose of the implant is primarily to achieve fullness of the upper half of the breast. The problem is that either your breast tissue or the implant will settle over time and this is unpredictable. Some settle more than others. Individuals with MWL tend to settle more than those with stable weights. I am sure you have seen considerable relaxation in your abdomen after the central body lift as well..

Discuss your concerns with your surgeon and consider seeking a second opinion but be realistic in your expectations.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

A redo breast lift and smaller sub mammary textured silicone gel implants may be your answer

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I have stopped putting implants under the muscle when I do a simultaneous breast lift. It is very frequent to see many of these patients develop breast that hangs off their implant and the implant often slips all over the place under the breast and outside the breast confines.

The best results that I can get come from putting textured gel filled breast implants under the breast and preforming a breast lift over the new implant during the same operation. This requires a surgeon experienced in this procedure so get several opinions and ask specifically to see before and after pictures. Ask about the specific technique the surgeon plans to use. By using textured gel implants the breast will close down around the implant. and the implant should stay in relation to the breast. This give you the best chance to have superior fullness and still have the breast and implant seem as one.

Carl W. "Rick" Lentz III, MD
Orlando Plastic Surgeon
5.0 out of 5 stars 17 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.