Dropped & Boxy Again - what causes this? (Photo)

Question

Nine months ago, I had a breast revision due to significant dropping of my breasts over the inframammary fold. Despite replacing 325cc silicone implants with 400cc gummy bear ones, both breasts remain boxy, dropped again, with flatness under the nipple and increased distance between them. I'm a 45yo female, 120#, fairly active. Unsure if my expectations are unrealistic or if this is my anatomy. Reluctant to undergo another revision. What causes this?

Carlos Mata, MD, MBA, FACS · Answer

Thank you for your question. If you have dropped or boxy-shaped breast implants, it is recommended that you undergo a revision treatment to tighten the lower breast region and enhance the roundness of the implants. The most common procedure involves removing a portion of the inferolateral capsule and tightening the pocket with permanent sutures before lifting the implants into a higher position. This procedure can effectively achieve a more natural and aesthetically pleasing breast shape. However, it is crucial to consult a board-certified surgeon who has experience in performing breast implant revision operations. They can comprehensively evaluate your case and advise you on the best surgical approach to achieve your desired results.

Finny George, MD · Answer

Hi, thank you for sharing your question. The reason for this is the skin laxity along the infra-mammary crease. This can be fixed with a revision procedure to tighten the lower breast and round it out.

Daniel Barrett, MD · Answer

Dear A.Class.Act,
I understand your concern. However, without a proper assessment, it would be difficult to determine what is wrong. If you had anchor lift, that might be the cause of boxy appearance. 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, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Jed H. Horowitz, MD, FACS · Answer

A Class Act
Dropped & Boxy Again 
can happen with a revision or the initial augmentation mastopexy
Breast problems requiring revision
BOTTOMING OUT
This is the term given to implant displacement, where the implant drops down below the existing inframammary fold (natural crease beneath your breast). This may occur when the fold has been released excessively during surgery or may be due to factors of the patient’s collagen and tissue integrity. The implants end up sitting very low on the chest and there is lack of internal support for the implant itself.
Correction usually involves restoring the crease beneath your breast to its normal position. This involves internal reconstruction including the capsule around your implant (capsulorrhaphy). Sometimes a biologic fabric (Acellular Dermal Matrix) can be used to attach to the breast tissue internally and support the implant.
This corrects the placement of the implant, redefines the breast shape, and refines the internal fold.
For you changing the profile of your implant and size along with a mesh may be helpful
STRETCH DEFORMITY
This occurs when the breast fold is in the correct position, however, the length of the tissue between the nipple and the fold stretches. This may be due to the patient’s soft tissue inelasticity and/or the size or shape of the implant that is used. Skin laxity can change with age, pregnancy, weight changes, or heredity.
Correction of this problem usually includes skin excision as part of a mastopexy (breast lift/reshaping).
It may be necessary to use ADM to further support the breast tissue if too thin.
CAPSULAR CONTRACTURE
This is a condition where the capsule around the implant thickens and squeezes the implant making it hard and often changing the shape and position of the implant. It is more common in nicotine users (e.g. smoking or nicotine patches or gum). Effective treatment of the capsule frequently involves completely removal of the capsule (capsulectomy), and occasional incisions in the capsule may be somewhat helpful (capsulotomy). In the past, closed capsulotomy, in which the breast is squeezed until the capsule breaks, was used. Currently, most doctors avoid this technique because of complications associated with the technique and because the implant companies will void their warranty if this technique is used. At times it is necessary to change the position of the implant, either above or below the muscle, depending upon the initial position, changing the implants themselves and, on occasion, the use of Acellular Dermal Matrix (ADM) may be required to prevent continued problems. Although the published risk of capsular contracture is approximately 9-11%, in our practice it is somewhat lower after initial implant placement. Once capsular contracture occurs, the risk of problems with secondary surgery rises to between 25% and 40%. The use of Singulair and Vitamin E may be of benefit. If you had a Sientra Textured Implant placed as a primary procedure and a contracture occurs in the first two years after primary augmentation, then their implant warranty may apply.

Ryan Endress, MD · Answer

You have what appears to be excellent skin quality, but that alone will not prevent the boxy appearance that you have. The soft tissue will tend to descend over time even with the implants placed in the proper position and the breast gland alone repositioned and sutured. That is a lot of mass for your small frame to support, and my approach to this would be to utilize a mesh construct attached firmly to the chest wall that will hold the implant in place and not allow that bottoming out. For the absolute best result from a shape standpoint, you might need to downsize the implants slightly to have a better ratio of soft tissue. Thanks,

Paul E. Chasan, MD, FACS · Answer

Thank you for your question. A large portion of my practice is dedicated to breast revision surgery. Many surgeons do not remove breast tissue when they perform a lift. Unfortunately, there is no easy fix. Many years ago, I pioneered a technique specifically for patients like you termed "Reductive Augmentation". This involves an internal bra-capsulorrhaphy, revision of the mastopexy-lift, and excision of the lower pole breast tissue.  You should be able to have a beautiful appearing breast with this technique. Best wishes to you

Gary M. Horndeski, MD · Answer

Your breasts are wider than your chest wall, too large for your frame and too low on the chest wall. At this time, I recommend removing the implants, revising the previous lift and have fat transfers to the upper pole of the breasts.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Karl William Schwarz, MD · Answer

Two reasons in my opinion. One is your breasts are a little on the wider side and it is hard to get a really round shape with a perky appearance with a wider breast and the second reason is the strength of your ligaments that attach your breast tissue to your chest wall. But overall I think you have a great result and your surgeon did a beautiful job and I wouldn't aim for perfection as it is not attainable for anyone and you look very nice. I am not just saying that.

Connie Hiers, MD, FACS · Answer

The heavier implants will just drop down from the weight and stretching your own tissue. Please do not go larger. A little trimming could be done in the lower lateral part of your breasts, but you will probably return back to this shape because of the implants stretching your own tissue that was already stretched, loose, and sagging.

Camille Cash, MD · Answer

From the photo it appears the implants may be too large for your frame.  A revision to the lift as well as different implants may yield a better result.  Adding mesh reinforcement would also add support.  I've included a video on this that I hope you find helpful.

Dropped & Boxy Again - what causes this? (Photo)

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