What can be done to help me achieve a more perky appearance after two failed breast augmentations and a capsulectomy? (photos)

I would recommend a new implant placed below the muscle through an incision in the fold. This will lead to the lowest potential chance of recurrent capsular contracture. You may need an areolar reduction (not a donut lift intended for lifting but truly just for areolar reduction). I do not think you need any more "lifting" but definitely need to fill the soft tissue envelope out with a moderately sized implant appropriate for your breast measurements.

In order to improve your results you will require another lift. You have some asymmetry that can be addressed at the time of revision. The areola can be downsized as well. See a board certified plastic surgeon near you for a consultation to learn more.

Thank you for your question. Fat grafting could be a great option for adding natural fullness, but unfortunately, it’s not possible in your case as you appear to have inadequate donor fat. However, you can still achieve a perky, more lifted appearance through a formal breast lift. This procedure can remove excess skin and tighten the tissue, lifting and reshaping your breasts to a more youthful position. Since you’re already comfortable with the size of your breasts, the lift alone can create the perky, tightened look you want without needing to add volume. During a breast lift, smaller areolas can be achieved, and it will give you a better aesthetic outcome and a more proportionate, balanced look. Given your history with capsular contracture and desire to avoid implants, a formal mastopexy without implants is likely your best option. It will lift and reshape your breasts, address the sagging, and tighten the overall appearance without needing volume from fat grafting or implants. This procedure can also reduce scarring using strategic incisions that heal well over time.