Do I need to decrease cc size? Capsulorrhaphy? With mesh or not? Opinions please

Question

I need a revision, I'm almost 1.5 yrs po from breast lift + 485 and 520 cc under the muscle HP silicone implants. My PS recommends a capsulorrhaphy but doesn't seem concerned with my size. He also mentioned galaflex possibly. Adding pics to get opinions on if size is too large for me and what revision would be best. I was bottomed out in both breasts by 3 mo po appointment and my ps didn't bring up my bottomed out breasts after I told my concern about rising scars

Gary M. Horndeski, MD · Answer

485 and 520 cc implants weigh over 1 lb each.  The weight of your implants has stretched out your skin envelope resulting in bottoming out.  These implants are too large for you to accommodate, will continue to fall and GalaFlex will only be a temporary solution.  You would benefit from explant, lift and possible fat transfer.  The technique I recommend 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.

Leland Deane, MD, FACS · Answer

Yes, you've bottomed out and the nipples are quite high. There is asymmetry as well. These changes are probably at least partially due to over-dissection to accommodate overly large implants. You would need a smaller implant, in my opinion, and reshaping of the breast capsule. Skin excision might be necessary. Alloderm support can be effective too but only if the above maneuvers are done too. Best of luck.Leland Deane MD FACS

Gerald Minniti, MD, FACS · Answer

Hello,Although your implant choice (very large, ball shaped, and presumably smooth) puts you at high risk for what happened to you, your body has demonstrated a predilection for smaller implants. So yes your implants are too big (for you), and not using Galaflex mesh would be fool hardy, especially if you stick to your current implants. Your revision surgery is tricky, and if your surgeon isn't expert in revisions, you should visit a few others for a second opinion. Best of luck!

Robert P. Schmid, MD · Answer

Thanks for your question, & including your photos, they really help! Based upon your photos and my experience of doing thousands of breast augmentation surgeries, I’d say that you certainly don’t need to increase your cc’s. I’d leave the same implants in & simply do an inferior capsulorrhapy (tightening your implant capsule on the bottom) while also doing a superior capsulotomy (breaking open the implant capsule on top so that the implants will migrate superiorly). I don’t think that you’ll need Galaflex or any other ADM. best of luck to you!

Larry Weinstein, MD · Answer

It looks like the implants you have are a bit large for your frame, also the nipples are fairly high relative to your mound. An inframammary fold reduction could fix this with slightly smaller implants. Good luck...

Daniel Barrett, MD · Answer

Dear Midcitieabeauty,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

David Azouz, MD, FACS, FRCS(C) · Answer

The pictures suggest “sunny side up” breast implants.  This means that there is far too much inferior poll fullness and not enough superior poll fullness.  It gives the breasts a “bottomed out” look.  Revision options do include procedures that do not involve mesh.  Size is very dependent on the patient’s wishes and it is possible to be smaller or the same size according to the patients desires.

Kamran Khoobehi, MD · Answer

Your before picture shows sagging and small breast. Your after pictures show bottoming out and large implants. You will have the same issue if not reduce the size of your implats no matter what is used to support the breast.Please see the link for example.

Mark Eberbach, MD · Answer

your pictures are good and help a lot. Bottoming our is all too common with lifting and augmentation at the same time. A smaller implant and soft tissue support by Galaflex will work along with a capsulorraphy. We have had other mesh come and go. It seems that Galaflex will remain a good option.

Tom J. Pousti, MD · Answer

I am sorry to hear about/see the problems you are having after breast augmentation surgery. I think your concerns are appropriate; your breast implants do seem to sit quite low on your chest wall, consistent with breast implant displacement ("bottoming out”).
 Generally, signs of breast implant bottoming out include: 
1. Breast implant "sits" too low on the chest wall.
2.  Excessive palpability or visibility of the breast implant along the lower breast pole.
3.  Nipple/areola complex seems to be sitting relatively high, because the breast implants have settled too low. 
4. Discomfort along the lower breast pole (secondary to pressure from the underlying implant).
5. Relative paucity of upper pole breast implant volume compared to lower pole volume.
6. Increased visibility of a infra mammary fold scar (higher on the breast mound).

I think you will benefit from revisionary breast surgery which will likely involve capsulorraphy ( internal suture repair). Sometimes, depending mainly on the patient's history and physical examination, I will also use additional supportive materials such as acellular dermal matrix or biosynthetic mesh. This procedure serves to reconstruct the lower poles of the breasts and prevent migration of the breast implants too far inferiorly. Associated issues with positioning of nipple/areola complexes and visibility of the inframmammary fold scars should improve with this operation.In my practice, the size and profile of breast implants decision making is usually made during the procedure, once the breast implant displacement problem is corrected (and after the use of temporary sizers and careful consideration of the patient's goals and measurements).   I tell my patients undergoing this type of operation: the priority has to be correction of implant malposition (and avoidance of recurrence of malposition).  For patients seeking a larger outcome, I do my best to achieve size goals as well (keeping in mind the first priority).
 My best advice: make sure that your selected plastic surgeon has significant/demonstrable experience helping patients with this type of revisionary breast surgery. Careful preop communication and careful attention to restriction of postoperative activity are also very important when it comes to successful outcomes.
 I hope this helps.

Do I need to decrease cc size? Capsulorrhaphy? With mesh or not? Opinions please

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