Best revision approach for implant rippling (photo)

Question

I had Sientra 350cc mod profile placed 12 months ago. They were placed over the muscle (subfascial). I am thin and I was an A cup prior. My surgeon prefers subfascial. When I asked them about a revision for the rippling, they are recommending that I stay subfascial and choose a more cohesive implant. With my rippling, would this be enough or should I request an under the muscle approach? Any brand recommendations to reduce rippling? Thank you!!

Daniel Barrett, MD · Answer

Dear Mercury122,

breast revision surgery is the most difficult plastic surgery procedure performed. Botched breast surgery alters normal tissue planes and laxity, the ability of breasts to heal properly, and leaves scar tissue that dramatically affects the level of difficulty of the corrective surgery.
Many patients come in to correct poor outcomes from their initial surgeries. The most common problems are due to implant malposition, bottoming out of the implant, poor scarring, and incorrect implant size.
While the type of revision required will depend on the result of the previous surgery and the desired result of the patient, some revisions involve extensive pocket repair that may or may not need specialized external bras.
If you are considering breast surgery revision, you should speak with a board certified plastic surgeon and have yourself properly assessed. Only after a thorough examination you will get more information and recommendations. Also, you have to make sure that your surgeon understands your breast augmentation goals.

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

John Michael Thomassen, MD · Answer

An exchange of the implant pocket to submuscular should correct this.  Also the use a more cohesive implants, acellular dermal matrix, and fat grafting can correct this.

Matthew S. Kilgo, MD · Answer

Hello and thank you for your question.
Visible implant rippling occurs because of a combination of two factors: thin soft tissue coverage and the cohesivity ( gel thickness) of the implant utilized. Accordingly, it can be treated by either increasing the soft tissue coverage or the cohesivity of the implant, or a combination of both. If your surgeon used a style 106 implant, a more cohesive choice would be the 107 HSC+ implant. Alternatively, other manufacturers also have highly cohesive gel implants. The quality of soft tissue coverage can be increased by either placing the implant below the muscle or by adding fat grafting to your procedure. In my opinion, the most effective means of reducing  the likelihood of  rippling  is to place a highly cohesive gel implant below the muscle. I hope this helps. Good luck.

Gianfranco Frojo, MD · Answer

I would recommend switching the implant into a submuscular dual plane pocket. This will provide better soft tissue coverage of the implant. I would also recommend switching to a more cohesive silicone gel implant. Higher cohesivity more filled silicone gel implants ripple way less. Another option would be to fat graft the areas but this is not necessarily addressing the problem which is implant rippling that is visible through a very thin soft tissue covering. The fat grafting is also more unpredictable given 40-60% of fat graft survival.

Gary M. Horndeski, MD · Answer

Placing the implant submuscular will widen your cleavage but will conceal the rippling much better. Right now, the only thing between your skin and the implant is a very thin layer of fat. You may also want to consider fat transfers to this area to thicken this area without damaging the implant at the same time. I recommend a highly cohesive gel implant to minimize the rippling effect.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Paul E. Chasan, MD, FACS · Answer

Thank you for your question. Medial/center rippling and subfascial implants is extremely common.  It is one of the most rookie mistakes that I think surgeons make.  I have been in practice for 30 years and revisionary breast surgery is a large portion of my practice.  The fascia on top of the pectoralis major muscle is about as thick as tissue paper.  There is no substantial difference between subfascial and subglandular.  That means that in thin people the only thing between you and your implant is skin.  It is very predictable and it is stupid surgeon stuff.  In your case, I would change you to a subpectoral location and use a higher profile implant.  The wrinkling will be completely gone.  You should be able to have a great result.  Best wishes to you.

Dana Goldberg, MD · Answer

Hi. I don't know why some surgeons are so obsessed with the subfascial plane. It's not a thick tissue layer, and rippling can happen in thin patients. I have tried simply using more cohesive implants to minimize rippling, and it just doesn't work that well in most cases (unless the prior implant was an under-filled saline or a generation 4 silicone implant).

The most cohesive implants on the market are Natrelle's cohesive, but there are cohesive options from all the manufacturers. You also want to make sure the implant is "overfilled" (most are these days). I've found that in addition to increasing cohesivity, I often have to change something else to really address the issue.

The options are to change to a sub muscular plane (which does come with a risk of animation deformity) or add a tissue graft like alloderm, strattice, or a non-biologic like gala flex to help thicken the tissue. Fat transfer is also an option (if you have any fat to "donate" to the area). A non-surgical option is injection of Renuva (injectable powdered stem cells of fat) to add tissue thickness. There are pros and cons to each of these options, and none are 100% guaranteed to work. I'd consider how much this bothers you and discuss these options with your surgeon.

Gerald Minniti, MD, FACS · Answer

This is, at least, one of the problem with the subfascial fad. Even with the very limited view in the photo you were not a candidate for anything other than subpectoral placement (I can see the contour of the sternum articulate with your third rib). Switching to the highest cohesive gel implant available, Natrelle Inspira cohesive, you will still have rippling. Even if you have suitable donor sites for fat harvest, grafting that fat in the razor thin tissue covering your implants next to your sternum will not be sufficient. You really should cut your losses and replace under the muscle.

Harry T. Haramis, MD, FACS · Answer

Upper inner rippling, evident at rest,  in thin patients, can be more visible with implants above the muscle.

Options include placing the implants under the muscle, which will shield the area. Some patients may get muscle animation and different projection under the muscle or half (dual plane).

If you want to stay above the muscle, then a biological mesh such as Strattice can be easily added to cover the rippled area.

Further consultation with your/a plastic surgeon is recommended.

Connie Hiers, MD, FACS · Answer

Stay with gel implants, go smaller, and place them behind the muscle for best coverage. The fascia is not coverage enough, or consider adding mesh. If you have donor fat, consider a fat transfer as well.

Best revision approach for implant rippling (photo)

Answers (12)

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