Minimal breast tissue - ripples and dents showing. What are my options? (Photos)

Question

I’ve had breast implants previously under my muscle. These implants are now on top of the muscle after having an uplift which I had done about 6 years ago. I’ve been told I have minimal breast tissue which is why you can see the implant ripples and dents. I was also advised I can have fat transfer however the surgeons feels I may not have enough fat for this. What are my options? I’m happy to go slightly bigger if necessary but would prefer not to go smaller.

Andac Aykan, MD · Answer

Hello, thank you for asking this question and attaching your photos.
What you’re seeing is due to very thin tissue coverage now that your implants are above the muscle. This makes rippling and dents visible and it won’t improve on its own. The solution is to increase coverage over the implant. This is usually done by changing to a more cohesive silicone implant, moving the implant back under the muscle if possible, and or adding fat grafting to thicken the tissue. Even small amounts of fat can help, depending on availability of your fat deposits.
Going with a larger implant can sometimes smooth the contour, but it must be done carefully since the added weight from the implant can worsen the problem long term. Leaving the implants over the muscle with minimal tissue will continue to show rippling.
A combination approach is usually needed.
Andaç Aykan, MD, Assoc. Prof.

Chet Mays, MD · Answer

Thank you for your inquiry!  We would love to sit down with you to discuss your concerns.  Fat transfer or alloclae transfer to the breast is an option.  Schedule a consultation with a Board Certified Plastic Surgeon to help you reach your goals.

Luis A. Mejia, MD · Answer

In my opinion, this is due to thin breast tissue with implants now over the muscle. The best solutions are a pocket change back under the muscle (dual plane), possibly slightly larger, softer implants, and fat grafting. Going smaller won’t help.

Whenever you’re ready:
Let’s make it better.

Warmly,
Dr. Luis Mejía, MD
Board-Certified Plastic Surgeon
CECILIP, Dominican Republic.

Whenever you’re ready:
Let’s make it better.

Warmly,
Dr. Luis Mejía, MD
Board-Certified Plastic Surgeon
CECILIP, Dominican Republic.

Jacob Carlson, MD · Answer

There are a few things that could potentially be done to address the rippling. Fat transfer is an option, but as you suggested, that requires that fat be harvested from somewhere else on the body. If you don't have enough fat to be used for fat transfer, another option is Alloclae, which is an injectable form of sterilized fat taken from a donor. Alloclae can be a bit pricey, depending on how much fat is needed. From a technique perspective, the fat needs to be injected into the breast tissue overlying the implant. If there isn't any breast tissue to inject into, then the fat that is transferred to that location won't survive. Based on your photos, that would be my biggest concern with the fat transfer option in your case.
You could also consider having the implants placed back into the submuscular pocket. I'm not of the reasoning for why your implants were moved to 'on top of the muscle,' but having the muscle covering the implant could reduce the amount of rippling that you see.
Another thing that you could consider is changing the implant to a more form-shape implant. Silicone implants that are more cohesive tend to have less rippling than saline implants or silicone implants that are less cohesive.
A surgeon might also recommend a combination of the the above options, depending on his/her experience.

Daniel Barrett, MD · Answer

Dear Triciab1986,

I understand your concern. However, without a proper assessment, it would be difficult to determine what is wrong. It is best that you visit your plastic surgeon for further assessment or ask for a second opinion. Only after a thorough examination, you can get proper recommendations and advice.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation (“overs”):

•	Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster 
when compared to subpectoral augmentation.

•	Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).

•	Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.

•	Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.

Subpectoral Augmentation (“unders”):

•	Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pectoralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.

•	Subpectoral implants have a lower rate of capsular contracture.

•	Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.

•	The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

With regards to your specific question, I would recommend returning the implants to the submuscular plane. This will provide greater camouflage in the upper pole. The lift can be revised to remove residual excess skin which can contribute to the rippling you are seeing. If there is still concern for visible rippling in the lower pole a support mesh can assist in smoothing.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other.  As always, your board certified plastic surgeon can help guide you in your decision making process.

Arthur Dean Jabs, MD, PhD, FACS · Answer

The best option in your case is to have the implants placed below the muscle and possibly adjust the skin volume from your lift as well as making the pocket slightly tighter.
Breast shape is determined by the skin “brassiere” and the underlying tissue which is fat and gland.
Thin women who have augmentations often have very little breast tissue/fat. When the implant is placed above the muscle there is little to cover the implant. When you lie down, as in the photo, the implant ripples that may not be evident when upright begin to show. You may have upper pole ripples in the upright position as well. 
Going under the muscle helps alleviate the upper pole wrinkles by adding a layer of muscle to the upper pole. 
Recalcitrant rippling in the lower pole may be helped by placing a “liner” of Strattus, a dermal tissue, that can add volume.

All the Best,

Dr. Jabs

Camille Cash, MD · Answer

The options you have been given are correct.  Placing a silicone implant beneath the muscle will help camouflage at least a portion of the implant.  Using bioabsorbable mesh is another option. Going with a larger implant is not likely to improve your concerns.  I've included a video that I hope you find helpful.

Karl William Schwarz, MD · Answer

I think your best option in this situation where you don't have any fat to use is to replace the implants under the muscle but your muscle is probably shortened and retracted so a piece of Strattice could help establish the implant pocket under the muscle and also provide you with more soft tissue which is really what you need.

Alloclae is a newer cadaveric fat that is used for people in your situation where they don't have any usable fat of their own. That could be combined with the above procedure as well. The implant size will not really have a significant impact on the rippling alone but I would personally use a round Motiva implant as they are filled to 100% and have less risk of rippling.

Asu Deniz Burhanoglu, MD · Answer

At this stage, the implant needs to be removed. After removal, we recommend waiting approximately 6 months to allow the tissues to heal completely and for the swelling to subside. Following this period, fat injection can be performed, or alternatively, a new, larger implant may be placed.

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