Options for dent/rippling in one breast after nipple sparing bilateral mastectomy with direct to implant reconstruction? (photo)

Question

5 months out from mastectomies & immediate implants w/ Alloderm. IMF incisions. 371g removed on left, 446g removed on right, and 435cc Natrelle Inspira put in. Thrilled with left. Have concerns with right. I know rippling is not unusual with thin tissues after mastectomy, but I have a large always-present visible dent and I can feel the rippling at outer edge of implant and it sometimes causes pinching/discomfort from movement. Some extra skin at bottom as well. Options and recovery time?

Martin Jugenburg, MD · Answer

Correcting rippling is tricky.  You seem to have a great result and any further surgery will always carry a risk of complications.  You can potentially worsen a good result in pursuit of a better result.  So the question is, does this bother you enough for you to take that chance?  If you want something done about it, fat grafting may be helpful but can't guarantee a perfectly smooth result.  Fat grafting is somewhat unpredictable and may not be successful.

Larry S. Nichter, MD, MS, FACS · Answer

Breast Implant Rippling most often occurs when there is insufficient soft tissue coverage due to little overlying body fat and breast tissue. Implants placed beneath the muscle help to minimize this phenomena but the lower and outside breast (as pectoralis muscle is no longer present), towards the cleavage where the muscle thins out or on top of the breast where breast tissue is often lacking are the most common places to see rippling. It is often accentuated with certain positions (e.g. bending over,or leaning). Most of the time, rippling is felt along the outer side of the breast and the inner side of the breast next to the cleavage. Breast implant waviness (rippling) that is felt but not noticeable to the eye is very common and should not be a concern. However, when rippling is visible, patients are often self-conscious about their appearance.Factors that are associated with increased rippling include:Traditional Saline implants (IDEAL® Saline implants less likely)Textured implantsLarge implantsThin patients with low BMIImplants placed above the musclePrior history of ripplingFactors which are less likely to have rippling include:Heavier and larger breasted womenUsing a highly cohesive form-stabile silicone implants (gummy bear)Smooth implantsSmaller implantsSubmuscular placementOnce rippling occurs it is very difficult to correct. Rippling can be minimized by placing a biologic fabrics (e.g. AlloDerm®, Strattice™, SERI®), submuscular conversion if implants are above the muscle, fat transfer, use of adjacent tissue (muscle or fascia) if available, and in persistent cases implant removal and fat transfer. Seek the care of the best board certified plastic surgeon possible with experience in breast revision surgery.#rippling#breastaugmentation

Lewis Albert Andres, MD · Answer

Hello!  Thank you for your question!  Fat grafting has become a popular 
procedure to improve aesthetic outcome following breast reconstruction 
or for improvement of contour after lumpectomy.  Much of the newest 
research has investigated the properties of fat, in terms of its stem 
cell properties and associated advantages.	It has significantly 
ameliorated radiation damage by increasing vascularity.  Also, it adds 
additional "fatty tissue" atop the reconstructed breast mound to further
 contour any concavities or deformities, while also masking implant 
visibility with rippling and such.At our Breast Reconstruction 
Center, we have utilizing this technique almost routinely to maximize 
the aesthetic outcomes after lumpectomy or mastectomy.  We have utilized
 the micro-fat grafting technique, and have been obtaining maximal fat 
graft survival into the breast.  After harvesting of the fat from areas 
with excess fat, usually the belly, hips, or thighs, the fat is 
processed and injected back into the breast using the aforementioned 
techniques.  Our patients have been very happy with the results as well 
as the areas where the liposuction was performed.  Contour has been much
 improved using the micro-fat grafting technique, and the downtime is 
minimal.  Survival rate of the fat is reports 60-90%, and thus is 
usually compensated for upon injection of the fat.  Sometimes it takes 
multiple procedures.  	Fat grafting has become a mainstay in 
breast reconstruction and has added another edge to breast 
reconstruction for aesthetics with minimal morbidity and complications.  Best wishes for a great result!

Options for dent/rippling in one breast after nipple sparing bilateral mastectomy with direct to implant reconstruction? (photo)

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