Follow Up Implants Still Too Far Apart and Under my Arm. 3 Months Post Op. What To Do? (photo)

Pre op I was 32A. I got 265cc Natrelle/full projection/round/textured/silicone gel. Under muscle/aerola incision. Surgery date Feb 6/12 I posted here b4 about my breasts being too far apart & I understand it may have to do with my anatomy, however I feel like the curve & swell is still mostly under my arm, especially when I lay down. They are still hard to push together into a bra, and still seem to be "stuck" to my chest. Still look uneven, & I have noticed some rippling when I bend over.

Doctor Answers 6

Textured implants ARE designed to adhere to tissues, so they won't move!

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Textured implants are designed to adhere to the tissues, which is one reason I believe textured implants have no place when used below the muscle. Textured surfaces were developed in the late 1980's when most implants were placed below the breast (ABOVE the muscle) and there was a much higher incidence of capsular contracture.

We now know that CC occurs primarily in the settings of bleeding and bacterial biofilm formation. Below the breast positioning (above muscle) exposes the implants to significant numbers of intraductal bacteria, and smooth implants in this location allowed the bacteria to move freely along and around the smooth implant surface. Implant surface texturing provided adherence, isolating bacteria into localized macro-pockets between the irregular textured surface peaks and valleys, while also "breaking-up" vector forces of collagen and myofibroblast contraction. Some studies have shown that texturing seems to reduce capsular contracture in submammary implant placement; other studies are less convincing.

When the FDA restricted use of silicone gel implants in 1991, plastic surgeons were forced to use primarily saline implants for cosmetic augmentation, but when used in the above-muscle position most of us were "used to," patients began to notice rippling and water-balloon feel, so most plastic surgeons started placing implants below the muscle. Including those who used textured implants above the muscle.

However, below the muscle there is significantly less bacterial contamination, since the breast ducts are above the muscle. Less CC occurred, and some PS felt this was due to their use of textured implants rather than the much-lower bacterial load of the submuscular position. However, some degree of lateral breast movement is natural when reclining, and only smooth implants allow that. Textured implants cannot move, and only the (small amount) of your own natural breast tissue moves, even less so if you have CC.

I am explaining this so you understand that even though it is a surgeon's (and patient's) choice as to smooth or textured, and above or below the muscle, there should be some degree of thought and reasoning behind the decision other than "This is the way I've been taught" or "That is how my professor did it" or "that's what my girlfriend has and hers look nice." Habits are bad when new information or better science goes unnoticed. Clinging to old ideas out of stubbornness or "routine" is equally wrong. But back to you.

Your implants are too narrow (full projection=high profile) for your breast base width, giving you the "curve and swell" under your arm and the wide cleavage you mentioned earlier. Texture has prevented them for dropping into better downward position over time (as smooth implants would), and rippling is evident because your implants are soft and you have not developed CC. Even silicone implants can have some rippling, though generally much less than saline, and much less than above the muscle.

Your result isn't bad, but you aren't happy either. You would have better results with smooth round implants below the muscle in a wider profile implant choice. If you like your size, then (for sure) you need mod + or even wider moderate profile implants; if you would prefer bigger, then the larger implant size will have a correspondingly wider base and moderate may still be best, or more likely a moderate + profile.

Time won't help your result because of the adherence of your textured implants--they can't "settle" or drop into better position, not to mention being better in the cleavage area or less in the under arm areas. I'm sorry to tell you that revision seems to be in your future if you remain unhappy with your present appearance. I'd suggest consultation with additional ABPS-certified plastic surgeons experienced in breast surgery, and hear their philosophies about the choices they make, and why. For more information, click on the web reference link below. Best wishes! Dr. Tholen

Minneapolis Plastic Surgeon
4.9 out of 5 stars 263 reviews

Lateral Displacement of Breast Implants?

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Thank you for the question and pictures.

If you find that your breast implants displace laterally ( especially when you lie down), you may benefit from revisionary breast surgery at some point. This operation may involve internal sutures placed along the sides of the breasts (lateral capsulorrhaphy).  Closing off the breast implant pocket on the sides will serve to prevent breast implant migration to the sides (laterally).  Judicious opening of the breast implant pocket mediallly ( close to the cleavage area) may also help improve the breast implant positioning and your level of satisfaction with the results of surgery.

I hope this helps.

Follow Up Implants Still Too Far Apart and Under my Arm. 3 Months Post Op. What To Do?

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The photos demonstrate a pre operative asymmetry that was not considered in the choice of same sized implants. As for the supine lateral displacement I find your result acceptable. You need to discuss why the same size implants were used in an asymmetric volumed breasts (left was smaler than right and higher inframammary crease)

How to improve my breasts? (photo)

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Your questions and difficulty with the implants are not uncommom, but I believe must be evaluated carefully in person, preferably by the operating surgeon, to develop a treatment plan that is most likely to suceed.   You submit good photos, but there are multiple technical aspects of surgery the online responder cannot know.  In general, to keep implants from lateralizing in supine position, textured implants good choice.  Width of implants should be broad enough to extend close to midline, as your pre-operative breasts do.   Positioning implants at surgery mandates slight medialization relative to your lateral nipples.  Post surgical bra to prevent dynamic muscular lateralizing force and close post surgical follow up to be certain of satisfactory developing result also important, in my opinion.

Steve Laverson, MD
San Diego Plastic Surgeon
4.9 out of 5 stars 50 reviews

Implants and pocket

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First, you are limited by your anatomy a bit.  In addition textured implants do not move as easily as smooth implants. Some uneveness is also normal as the breasts start off a bit asymmetric.

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

Post Op Questions

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You have raised a number of questions so lets take them one at a time.

1) There are a number of issues to consider with respect to positioning of your implants.  The pocket dimensions are an important element in where the implants will be located.  If the pocket extends to the side the implant will tend to fall to that area.  That is especially true when you are lying down.  All implants will fall to the side when you are reclining so it really is normal and just a matter of degree.  

2) With respect to your inability to push them together, it is important to remember that your implants are under the muscle and the muscle will stop the implants from going too close over your breast bone.  Women who have little breast tissue, as is evident from your preop photo, will generally have a wider cleavage than women who have more breast tissue that can fill in between the implants.

3) Your comment about being "stuck" to your chest might be related to the textured surface of the implants.  This surface is supposed to act like velcro so the implants attach to the surrounding tissue.  When this occurs the implants will have less mobility and often feel stuck. When women with more breast tissue use this type of implant they can still move their breast tissue over the implant but when there is little breast tissue the entire breast may feel immobile.

4) Rippling is a known problem with all implants, more so with saline than gel.  Again, the textured surface may be contributing to this but also the fact that you are thin so that any ripples that are present have a greater likelihood of being visible.  Bending over is the most common position in which ripples are noted in my experience.

5) You have used relatively small implants that are full projection.  Understand that full projection implants have a smaller diameter as do implants with less volume.  This will also impact the perceived width of the implant and your cleavage.  It is important to match the implant diameter to your chest dimensions.

Overall I think your result is quite reasonable but you obviously have concerns.  Speak with your plastic surgeon about them so you can have a better understanding of these issues and see if you have any options to address them.

Richard Kofkoff, MD, FACS
Saint Louis Plastic Surgeon
5.0 out of 5 stars 81 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.