Sizing: Saline to Silicone & Going Smaller with a Breast Augmentation Revision. Is It Possible? Advice?

1st PS says yes,2nd says no & 3rd tells me a completely diff story. 1st PS recommends under musc. HP gel imp (but says I will be 'fuller', not nec. bigger), 2nd PS rec. staying subglandular & switching to Mod.+ silicone.I'm 5'2/100lbs A cup-C cup.I don't want to wake up w/ a D cup if I choose under musc.route. Had implts since 03 & rippling is getting worse. Why am I getting so many diff answers? See current photos, please help w/any advice. I'm getting the revision, but want to do it right!

Doctor Answers 8

Revision Breast Augmentation Problems: Tissue Cover is Paramount!

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Were your breasts the same size before your surgery, or was the left one larger/droopy?  You can easily 'see the implants' through your breast tissue.  Why do you think that is?  This is a difficult problem, and not one I can explain in a couple of sentences.  This hopefully was all explained to you when you first made your decision to get implants done- but I suspect you are in this situation because it was not explained to you.

My impression is that you were mismatched initially with respect to the size of your original implants.  Ladies, your surgeon must match the size of your implants to the size of your breast and it has to be appropriate for the size of your body!   Do you go to the shoe store and choose the size of shoe that looks best or the one that fits your foot?   If you choose an implant size without understanding the consequences of your decision, this problem may happen to you too.

 Also, forget about talking about cup size.  There is no international standard cup size measure!  A 32 B cup bears  no easy relationship to a 40 B cup (have a look your self ).  Furthermore, a Playtex 36B is not the same as a LeJaby 36B- the volume of a cup size will depend on the band size as well as the manufacturer.  Every manufacturer has their own thing, and it is meaningless to talk about cup size, except to say for a 5'6" woman of average height, one cup size is about 200 cc of volume.   So, lets talk about volume, in cc's, because 200 cc is the same no matter who is measuring it.  You can measure out 200 cc of dry rice or wheat germ, put it in a zip lock bag and stuff it in your bra and get some valuable information from that.  Plus a surgeon in Toronto,  or a surgeon on another planet will understand what you mean when you say 200cc.  

 At 5'2" tall and 100lbs, your implants are so large that they have stretched out your tissues.  This is not brain surgery people- the larger the implants, the thinner a given amount of breast tissue covering it will become.  If you get larger implants, the tissues will be stretched out even more, and be relatively thinner.  That means that the implant will be EVEN MORE visible through your tissues.  Tissue cover is the MOST IMPORTANT factor in success in breast augmentation.   If you put a rock under a mattress, it will create a smooth lump. Put it under a silk sheet and it will look like a rock.   What this means is that women who have plenty of natural breast tissue can use many different types of devices and get an equally good result.  Women who have thin breast tissues to hide an implant will have restricted choices.  Thus, the SECOND MOST important factor is the type of device used.

The thinner the tissue cover, the more critical are the properties of the implant device (since it is, relatively speaking, more visible).  Implants which tend to wrinkle more or collapse more, for example, will have more wrinkling.    Textured implants will be softer, but will tend to have more wrinkling than smooth walled devices (this has to do with the pressure effects of the capsule around an implant).  Smooth walled devices in the submammary plane will have a thicker capsule and more pressure on the device, and the device will appear slight smoother, all other factors equal.

 Probably, the best type of device for you will be a solid implant, ie the gummy bear implant (Mentor CPG or Allergan 410).  These devices are designed to not collapse, ie they will not empty to the bottom of the bag like saline or liquid gel devices because they are solid devices, not liquid.  However, these devices are not meant to be used in oversized pockets, so they can NOT be used at the same time as old implants are being removed.  Also, they are meant to be inserted into a fresh surgical pocket, not into an established one- this is a critical factor (I have been using these for almost 10 years).  Between the two devices, the CPG is softer and slightly less filled than the 410.  For these reasons, i would choose a 410 device for you since it is slightly fuller and less prone to collapse.  The critical issue here for you is that it can't be done at the same time as your old implants are removed, because that will lead us towards even more problems of malrotation and malposition.

So what are your alternatives?  If you get a larger device, that is obvious- you are going to have more problems (larger device=thinner tissues= more problems= more money) .  If you get a significantly smaller device, and IF your skin elasticity is NOT good- what do you think will happen?  A tennis ball in a sock is a good analogy here.  If I were you, I would seriously consider just having the implants removed, along with a hemicapsulectomy.  I call this the "igloo" operation, because the capsule anterior (in front of) the implant should be removed when the implant is removed.  If you leave the entire capsule in place,  you may have issues with recurrent seroma formation in the implant pocket, and the pocket will have a hard time closing up.  If a single layer of the pocket is left behind, the body tends to resorb it over a period of time.  You could have a complete capsulectomy (removing both the anterior and posterior layers of capsule) but that is more surgery, but that is also a reasonable course of action.  It is NOT reasonable to leave the entire capsule behind (unless the surgeon does some other fancy stuff which I don't want to get into) , and that is my point.

  The skin will retract somewhat, but it is an unknown quantity.  It may retract a little bit, or it may retract quite a lot- we just don't know.  When things have returned to normal- by that I mean that the tissues are COMPLETELY soft and that all healing has taken place, with NO EDEMA (doc-talk for swelling),  then you can reassess the situation and decide what you want to do.  Depending on how large of an implant you want, you may need to have a breast lift, or maybe an implant alone will be a reasonable solution.  If you have, for example 350cc implants now, and you went down to a 245gm implant, you might be OK, it is hard to know on the basis of a single photo.  Obviously, you need to have an expert examine you and guide you through this.

A word about High Profile implants: These things are not meant for people like you.  They are narrower in the base and push forward more (skinny and tall devices), and they were initially designed for post mastectomy.  That will put even more pressure on  your breast just under the areola,  just like a full uterus does to  the tummy skin just above the belly button at term.  What do you think that will do to the thickness of the tissues of your breast?  Yes, it will thin it out even more!  Does that sound like a good idea to you?  I hope you are following me here.  Unfortunately, some surgeons are using these high profile devices to fit larger volumes into patients who have a narrow breast base diameter.  It is not wise to try to cheat mother nature, IMO.

After your implants are out, and once the tissues have completely healed, then you can consider a type II or III of dual plane procedure, where an implant is placed under the pectoralis muscle,  and then the muscle is released from the breast to about the level of the areola.  Then you can use an Inamed 410 device under the pectoralis muscle and be safe in doing so.  I hope I have helped you understand the complex interplay between the types of devices, the types of pockets, and the complicated series of interconnected concepts that are important in fixing your problem.  You definitely need to find an experienced surgeon.  Best of luck to you.

Claudio DeLorenzi MD FRCS

Toronto Plastic Surgeon

Implant exchange

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The rippling in the upper pole should get better with palcing the implants under the muscle, but you may stil have it in the lower pole. You may need alloderm as well.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Downsizing implants

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Given the visible rippling in the upper protions of the breast, Iw ould hihly recommend that you consider implants placed under the muscle. As to size, it depends on your preferenc for a laorge or smaller  breast.  

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

Rippling in the Upper Pole of the Breast

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Sizing: Saline to Silicone & Going Smaller with a Breast Augmentation Revision. Is It Possible? Advice?

1st PS says yes,2nd says no & 3rd tells me a completely diff story. 1st PS recommends under musc. HP gel imp (but says I will be 'fuller', not nec. bigger), 2nd PS rec. staying subglandular & switching to Mod.+ silicone.I'm 5'2/100lbs A cup-C cup.I don't want to wake up w/ a D cup if I choose under musc.route. Had implts since 03 & rippling is getting worse. Why am I getting so many diff answers? See current photos, please help w/any advice. I'm getting the revision, but want to do it right!

I am not sure why you are getting some many different opinions.  Your problem is pretty obvious and can be addressed with placement of silicone implants behind the muscle.  This will cover up all the rippling you have medially and superiorly.  A more expensive option is to stay subglandular and place strattice or alloderm to give more tissue coverage.  I am not sure why anyone would choose the latter option.  If I were to perform your surgery I would recommend silicone implants placed in a submuscular postion.

Good luck.

Farbod Esmailian, MD
Orange County Plastic Surgeon
5.0 out of 5 stars 88 reviews

Rippling after breast augmentation can be corrected.

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1) Simply switching to silicone implants over the muscle may not correct your rippling. You need either under the muscle placement, or else the upper breast tissue can be reinforced with Alloderm.

2) High profile implants are overfilled and less likely to cause rippling.

3) There is no substitute for examining you, but I would side with 1st PS.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

Switch to Silicone under Muscle Should Improve Rippling

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Changing your saline implants to silicone implants placed under your pectoralis muscle should give you the best chance of correcting your rippling.  You could change to a slightly smaller implant, but if you do, you might also consider a small verical lift.

John Whitt, MD (retired)
Louisville Plastic Surgeon

Rippling breast implants

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If you ask 10 doctors their opinion about anyting including the time you will likely get 10 different answers. In your specific case the photos show capsular contracture (the edges of the implant do not blend into the surrounding breast tissue), rippling especially on the left upper half, no cleavage, some right left breast asymmetry and implants that lie below the lower edge of the pectoralis major muscles in a thin apparently short individual. I doubt you have any fat elsewhere on your body in any meaningful amount to transfer to the breast area. If you place any breast implant above the muscle you have little or no native tissue to cover the edges of it. Saline implant edges blend in much less than silicone gel implants by their very nature. Therefore saline implants above the muscle is not a good choice for you as you have found out. Since there is not incision scar on the breast I assume the implants were placed via an incision under the breast. Since they are saline you may have had them placed via the belly button (a TUBA procedure). You are not the type of patient who should ever have a TUBA.

GIven your current situation you are at high risk of recurrent visible rippling and capsular contracture for new implants placed above the muscle without an adjunctive procedure like fat grafting or acellular dermal grafting to increase the native tissue thickness in the area. Putting implants below the muscle increases the amount of tissue between the edge of the implants and the outside world and is a very good option in age appropriate individuals with little or no breast sagging and thin native tissues. No matter what you do you cannot create cleavage that you never had.

I would also suggest going with a cohesive gel as well. You will not wake up with a D cup just because the implant was placed under the muscle. You will wake up with a D cup if you replace these implants with ones that are too large for you. Whatever you do make sure the surgeon you choose for the revision asks for and sees the operative report of the previous surgeon.

Aaron Stone, MD
Los Angeles Plastic Surgeon

Silicone implants will help

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You have very thin tissue over the implants and this makes it hard to give you the result you seek. I will offer you another option and I have done this on many patients that have similar problem. I would use fat grafting to provide thicker tissue over the implant and then change your implants to silicone and under the muscle (same size). You are very thin and amount of the fat that available to harvest is very limited. I have removed and replaced the implants with fat grafting in many patients, but in you case the best option is the use of fat and implant. You can check my website for pictures.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.8 out of 5 stars 154 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.