Revisionary breast surgery
Much of the final “look” achieved after breast augmentation revisionary surgery depends on several factors:
1. The initial shape, size (volume of breast tissue), symmetry of the patient's breasts. In general, the better the preoperative breast appearance the more likely the breast augmentation “look” will be optimal.
2. The experience/skill level of the surgeon is important in determining the final outcome. For example, the accurate and gentle dissection of the breast implant pockets are critical in producing long-term well-placed breast implants. I personally think that these 2 factors are more important than any others, including type (saline or silicone) or model (low/moderate/high profile) of implant.
3. The type of implant used may determine the final outcome, especially if the patient does not have significant covering breast or adipose tissue. For example, some surgeons feel that silicone implants have a more natural look and feel than saline implants because silicone gel has a texture that is similar to breast tissue. Each patient differs in the amount of breast tissue that they have. If a patient has enough breast tissue to cover the implant, the final result will be similar when comparing saline implants versus silicone gel implants. If a patient has very low body fat and/or very little breast tissue, the silicone gel implants may provide a more "natural" result.
On the other hand, saline implants have some advantages over silicone implants. Silicone implant ruptures are harder to detect. When saline implants rupture, they deflate and the results are seen almost immediately. When silicone implants rupture, the breast often looks and feels the same because the silicone gel may leak into surrounding areas of the breast without a visible difference. Patients may need an MRI to diagnose a silicone gel rupture. Saline implants are also less expensive than the silicone gel implants.
Other differences involve how the breast implants are filled. Saline implants are filled after they’re implanted, so saline implants require a smaller incision than prefilled silicone breast implants.
On May 10, 2000, the FDA granted approval of saline-filled breast implants manufactured by Mentor Corporation and McGhan Medical. To date, all other manufacturers’ saline-filled breast implants are considered investigational.
As of 2006, the FDA has approved the use of silicone gel implants manufactured by the Mentor Corporation and Allergan (formerly McGhan) for breast augmentation surgery for patients over the age of 22.
4. The size and model of breast implant used may make a significant difference in the final outcome. Therefore, it is very important to communicate your size goals with your surgeon. In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural” or “C cup” or "fake looking" means different things to different people and therefore prove unhelpful.
Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup size may also be inaccurate.
I use intraoperative sizers and place the patient in the upright position to evaluate breast size. Use of these sizers also allow me to select the breast implant profile (low, moderate, moderate plus, high-profile) that would most likely achieve the patient's goals. The patient's goal pictures are hanging on the wall, and allow for direct comparison.
I have found that this system is very helpful in improving the chances of achieving the patient's goals as consistently as possible.
By the way, the most common regret after this operation, is “I wish I was bigger”.
I hope this helps.
Superior malposition of breast implants
I agree that your result is unacceptable. the good news is that superior malposition of implants is one of the easiest fixes for plastic surgeons who specialize in revisionary breast surgery. I agree with performing a periareolar approach and performing an inferior capsulotomy or partial capsulectomy. Your chances of success are very high.
Your implants will probably not settle any further after 4 months. Placing implants under the muscle through an axillary incision almost always look and stay too high. It is extremely difficult to place large silicone implants low enough in the submuscular pocket to look right...I don't even try. The submuscular pocket was not released enough along the breast crease. I would consider a revision through an inframamary approach to enlarge the pocket and release the muscle so the implant will drop. Good luck!
I agree that a revision is necessary at this point. It is unlikely that your implants will drop enough to be satisfactory after 4 months. A periareolar incision is appropriate as well. I do think that you would be better served with a lower profile implant. A Moderate Plus profile would give you a more natural look even after they are properly placed. HP profile tend to look very "torpedo like" even in the best situations for augmentations unless you were completely flat chested prior to the augmentation. I also recommend a breast strap after the repositioning for two full weeks in order to ensure the implants stay in the proper place while you heal.
I agree that the implants are too high. I think transaxillary approaches have a narrow "sweetspot" for getting ideal implant position because the space is created from above and outside the breast. I think a periareolar (or inframammary, for that matter) approach can help reposition implants by releasing the lower border of the scar capsule and possibly releasing breast tissue below the lower border of your pectoralis major muscle to let the implants sit lower in the breast skin envelope. Size may or may not be too large, as you may like the overall volume of your result. Whoever does your revision needs to be careful about not releasing the muscle near the breastbone border too much, or you may develop a degree of symmastia (both breasts touching each other without a defined cleavage border separating them) with these large implants.
Obviously, whoever you go with, make sure your plastic surgeon for the revision is board-certified by the American Board of Plastic Surgery.
Breast Augmentation Revision Requires Accurate Implant Position
The quality of outcome associated with primary breast augmentation and revision depend on several factors. Implant position is important. If adequate release of the muscle and or capsule was incomplete when the implants were placed under the muscle, the implants will sit too high. In addition, because you have a short nipple to fold distance, a large implant like these will likely give you too much superior pole fullness. Saline implants are heavier and tend to drop a bit with time. Silicone implants stay where you put them. This is usually a good thing, however, if the implants are too high with silicone, generally a surgical approach is required for reposition. I agree that an incision on the breast (periareolar or inframmammary) will allow the best visualization of the pocket to release the inferior breast and lower the implant. Strongly consider a smaller implant as well as this will help with the balance of implant position on your chest wall.
I think revision using a periareolar approach would be helpful. I agree with the other comments that the implants seems a bit too big for you. Having said that, lowering the fold along with capsulectomy will allow the implant to drop and you may be able to keep the same implants.
At six months after your last surgery, I would suggest releasing the lower aspect of your implant pocket on both sides - to lower the implants. The areolar approach would be most suitable for this.
Also, your new implant volume seems disproportional for your frame. You may wish to re-consider a smaller size to end up with a more natural appearing result.
Breast augmentation revision
The implants that were placed are too big for your breast. You appear to have a fairly short distance from your infra-mammary fold to nipple - thus your breast will not accommodate a large diameter implant. Furthermore, the trans-axillary approach, when done by unskilled surgeons, can result in implant malposition if the muscle is not divided properly - this could be the case with you. I think your plan for a peri-areolar revision is sensible, but stick with a smaller implant that fits well within the width of your breast.
Will a Revision Fix my High Implant Placement?
Yes a revision can help attain a beauty result. Just have the inferior pocket dissected correctly. Obtain a few in person opinions.