Pseudoptosis after explant - Is there any possibility subglandular smallish implants could work without needing a lift? (Photos)

Question

Hi. I had 500cc dual plane saline implants placed in 2008 and removed with local anesthesia only in 2016 (capsules were left in). Now after 2 kids my breasts are deflated and I want them fuller, but I do not want general anesthesia (long story). I have a surgeon willing to do subglandular while I’m awake but I’m worried it will cause worse sag or waterfall deformity. Is there any possibility subglandular smallish implants could work without needing a lift?

Emre Guvercin, MD, FEBOPRAS · Answer

Thank you for sharing your surgical history and preferences &mdash; your situation is more common than you might think, especially after kids and implant removal.Based on what you’ve described, it sounds like you now have:
True breast ptosis (where the nipple sits below the fold),Loss of volume and projection,And a preference to avoid general anesthesia.Here’s the key point: in true ptosis cases, placing a small subglandular implant without a lift won’t correct the drooping &mdash; and can sometimes make the breast appear more bottom-heavy or “waterfall”-like, especially if the nipple stays low while the implant pushes forward.If you're trying to stay implant-only and under local anesthesia, the results will likely fall short of your goal.
That said, you still have options:
A low-volume implant combined with a tailored lift (which can sometimes be done under sedation or local with nerve blocks in experienced hands)Or even an implant-free lift, especially if you're satisfied with a modest size and want a perkier shapeIn my practice, I use a technique called the Push-Up Lift, which reshapes and lifts your natural tissue without relying on an implant for support &mdash; and can often be adapted to minimize the need for general anesthesia.The best long-term result always comes from matching the procedure to your anatomy, rather than forcing a limited approach for convenience. You’re not out of options &mdash; you just need a plan that respects both your body and your preferences.

Donovan Rosas, MD · Answer

Patient concerns regarding the appearance of their breasts can typically be divided in two pools: volume, ptosis (droop). The procedures to address these issues are as different as the issues themselves. However, these concerns are not mutually exclusive. Many patients, whether they are aware or not, will benefit from both.
There are two factors which can help to answer the question of which surgery will deliver the most satisfying result: mastopexy, augmentation or both. Patients must first consider the position of the NAC (nipple areolar complex i.e. the pigmented portion of the breast) as it relates to the inframammary crease. If the nipples are at or below the level of the crease the patient may benefit from a lift or mastopexy. The breast lift is designed to elevate sagging breasts to a more youthful position. It also helps to reshape and tighten the skin of the breasts. This is typically accomplished via a periareolar (around the nipple) incision with or without a vertical incision. 
Mastopexy is an effective way to address sagging breast, however, the changes which accompany weight loss or pregnancy can also decrease volume of the breasts. When a woman wants the volume restored, or increased, a breast augmentation will also be needed in conjunction with mastopexy. Augmentation can help restore the volume loss which is well known to women following children. There are a number of options available to women considering augmentation ranging from size and implant type to access incision.   
A breast augmentation alone may also be appropriate if ptosis is mild. If the patient is comfortable with the natural appearance of the breasts but desires them to be larger, a breast augmentation alone is the right procedure.  Augmenting significantly ptotic or sagging breasts tends to magnify the problem. In these cases, a mastopexy performed in conjunction with an augmentation is preferred.
With regards to your specific question, it is important to remember that an augmentation will not lift. Trying to correct ptosis with volume often times necessitates higher volumes in order to auto-rotate the tissue (not technically a lift).
There is a procedure for every problem. To determine which technique is right for you, consult with a board certified plastic surgeon Patient should discuss their concerns with their physicians in order to make an educated decision.

Gary M. Horndeski, MD · Answer

You will need a breast lift using The Bellesoma Method. This will reshape your breast tissue creating upper pole fullness without implants, elevate them higher on the chest wall and more medial to increase your cleavage. Vertical scars are avoided, nipple sensation (in 95%) and the ability to breast feed are maintained if not injured during your previous surgery. Later, fat transfers can be performed if additional volume is desired.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Daniel Barrett, MD · Answer

Dear bmd07d88,

determining whether you need simply a breast augmentation versus a breast lift can be somewhat complicated. It depends on a number of factors including skin laxity and current nipple position. Generally speaking, if the nipples are lower than the inframammary line the patient will most likely need a breast lift. If the nipples are at or above the inframammary line we can generally get by with just a breast augmentation depending on the size of the implant the patient wants. I often still using implant when I perform a breast lift because it provides more upper breast fullness after the lift. To be sure a consultation with a board-certified plastic surgeon will help determine what the patient actually needs.

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

Sean Fisher, MD · Answer

It is difficult to say based on the photos that you provided, as elevated arms can cause the nipple position to appear higher than it actually is. However, you do appear to have a skin excess of the lower pole with relatively minimal ptosis. This would need to be confirmed on physical exam, however re-augmentation combined with a horizontal wedge excision of the lower pole skin may be able to give you a good aesthetic result while avoiding a vertical and peri-areolar scar. While every surgeon will have their own tolerance for offering procedures under local, this is not something that I would offer- as I would typically be recommending subfascial augmentation, internal mesh placement and horizontal wedge- the combination of these, at least in my hands, would be something that would be better served under general anesthesia.
Sean M Fisher, MD Aesthetic Plastic Surgeon Seattle, WA

Tuan A Truong, MD, FACS · Answer

Thank you for your question! With mild pseudoptosis, an implant can help correct the deflation you have noticed. However, a small implant may not be enough, as it depends on a variety of factors, especially if performing sub-glandular. Measurements such breast width, distance from neck to the nipple, nipple-to-fold distance and even the amount of skin pinch along the upper pole all play a role in implant selection and appearance. Discussing these things with your surgeon will go a long way in establishing expectations. Good luck with your journey!

Camille Cash, MD · Answer

More information is needed to determine if you could have an acceptable result.  Discuss with your surgeon what size you are wanting to be and how you want to look after surgery.  If you are wanting a full, perky look you will likely need to consider a lift.

Darryl J. Blinski, MD · Answer

Based on the post of photos, taking the photos holding a camera into a mirror their shadowing, so cannot see complete breast recommend have somebody take your photos so there’s no shadowing and repost or do a virtual consultation. The best new concept that is FDA approved is the use of the FDA approved fat injection called ALLOCLAE you would need 100 cc per side of these injections the fee to do that would be $30,000 Because the product has a high cost. This can be done under local anesthesia. Best to virtual consult with for a better explanation regards.

Mats Hagstrom, MD (license on probation) · Answer

The variable that determines if a lift is needed in conjunction with a breast implant has to do with the nipple position in relationship to the IMF(infra mammary fold). 
We can’t see the IMF because your breast are hanging over the IMF. 
To clearly see the relationship between the IMF and the nipple position, consider taking a skin marker and draw horizontal lines from the IMF to the midline.
The left breast will usually sit half an inch higher than the right side.
If you do this, then look in the mirror or have someone take a picture you’ll see if your nipples are at the IMF, above or below. 
If the nipple position is at or above the IMF, then we can usually place an implant without getting the double bubble look.
There is some subjectivity to this.
The slice of implant also has some impact on if a double bubble outcome will happen or not.
A conservative breast lift can also be done using local anesthesia either with the augmentation or as a second procedure, 
When it comes to having procedures under local anesthesia, you should make sure the surgeon has done quite a few of these previously.
Today I do almost all my procedures with patients awake using local anesthesia with mild sedation.
For the last decade I’ve been specializing in doing mostly liposuction and fat transfer.
There are a lot of advantages of avoiding general anesthesia, but sometimes having an anesthesiologist can be the right way to go.
There is a learning curve and skill involved with doing local anesthesia procedures.
You don’t want to be on the early part of the learning curve or you may have a painful experience.
Things like cauterizing bleeding vessels can be quite painful if the area is not completely numb.
My best recommendation is focusing your effort on provider selection.
In the hands of the right plastic surgeon, you should be guided in regards to the need for a lift or not.
I don’t know what your history has been with general anesthesia, but you should know that anesthesia can be tailored for individual needs. Anesthesia should be seen as more of a spectrum rather than yes/no or on/off. There are lots of good choices that can be helpful. 
It’s possible to have an anesthesia consultation before surgery for those patients who have concerns or have had a bad experience.
Good luck with your decision making. 
Mats Hagstrom MD

Pseudoptosis after explant - Is there any possibility subglandular smallish implants could work without needing a lift? (Photos)

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