Was my breast pocket just too small for the implant? (Photo)

Hello, there are several reasons why someone can a different appearance after surgery: pre-existing asymmetry, implant pockets were not made exactly the same, one implant failed to drop or the other bottomed out, capsular contracture, etc.  A proper assessment including evaluation of your preoperative photos would be needed to try to understand the cause.

but you do need a revision and the proper procedure can only be determined by an exam and listening to your expectations.  You are unlikely going to need a lift as your right side looks good and your nipples are close to level.

Hi, DanElan.  Reviewing photos is never like doing an actual exam, but your frontal views show pretty clearly that the left implant is malpositioned, being high, and that the implant position and breast gland are not balanced.  Additionally, because there is no expansion pressure on the nipple from the implant, compared to the right side, the nipple on the left is contracted and small. This can be due to a number of things (inadequate pocket creation and release and/or incomplete muscle release at the time of surgery, muscle spasm and/or unyielding lower pole tissues and/or an elevated breast crease causing upward implant migration after surgery and subsequent closure of the lower portion of the pocket and narrowing of the width of the pocket during healing, excess inflammatory response and tightening of the pocket during healing, and capsular contracture.  This, unfortunately, is not uncommon, especially with submuscular placement.  Three years out, pocket redevelopment and possible capsule removal/scar removal is likely the only thing that will improve the implant position and overall breast appearance.  There is definitely a risk of this redeveloping, and I would strongly encourage you to work closely with your surgeon and follow his/her recommendations -- especially if massaging is recommended. Regarding breast lifts, there are many differing opinions amongst plastic surgeons.  You may well have "needed" a breast lift from the very beginning, but I do not think performing a mastopexy would have had any direct impact on the implant pocket, implant position, and your current predicament.  Further, I do not think a mastopexy is the answer to the specific implant-related problems and should be considered based on other goals.  A breast lift definitely can provide better balance with an elongated breast and an implant, and can help minimize the "Snoopy nose" look, "double bubble," and a variety of other breast concerns.  However, as I tell my patients, a "breast lift" is really not a "breast" lift, but rather a nipple lift.  A mastopexy essentially centers the nipple; moves the distal gland that has fallen well below the crease, creating a shorter, more compact and rounded breast; and may, to a lesser degree, narrow and/or cone the breast.  However, the trade off is scars on the front of the breast, additional unique risks, and a somewhat "pasted on" appearance to the breast.Hope all goes well with your surgery!