Sagging After BL and BA? (photo)

I had BL and BA in March of this year. I had 600cc implants on top of the muscle. My implants are sagging very bad. My surgeon suggested a reconstruction to re-lift the breast and remove more skin. Why did this happen? Were 600cc too large?? Is it typical to have to pay for OR and anesthesia on a reconstruction when the original didn't take. I also do not like that I do not have a valley between my breast, when I am wearing a bra it pushes up so far it looks like I have a uni-boob.

Doctor Answers 11

Implants Look Large and Skin Looks Stretchy

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By all appearances, your skin looks to be very stretchy, and the implants seem to be too large to be adequately supported by the skin.  It would be helpful to see pre-op photos as well.  Seek a few respected opinions.  Right now, only the skin is supporting the implants.  It is worth considering going significantly smaller with the implants, and also worth considering sub-pectoral placement.  Best of luck.  

Long Island Plastic Surgeon
4.6 out of 5 stars 24 reviews

Breast implants can be too large for a patient.

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The distance from the areola to the infra mammary fold appears to be excessively long. Much of this might be due to the size of the implants.

Vincent N. Zubowicz, MD
Atlanta Plastic Surgeon
4.8 out of 5 stars 41 reviews

Recurrent sagging

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Yes, the implants were too large.  There are many options for what you may want done next and it is worth going on a few consults and getting different opinions.  The correction may need to be done in stages to get the best outcome and avoid complications.  

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 28 reviews

What to know when considering revision

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The answer to your question is not simple, and keep in mind that no one can give you specific advice online. However, 600 cc's is a very large size and the weight of these implants can be expected to stretch the skin since that is all that is holding them up. Tightening up the skin envelope will likely provide only a temporary fix in this situation. My recommendation is consider an internal bra procedure using Strattice or SeriScaffold (if available.)

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 56 reviews

Breast augmentation and breast lift

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A breast augmentation with a lift has multiple variables.  It looks like the implants may be too heavy for the tissue that you have or not enough pexy was performed.  AS for the closeness of the implants pre-op photos would be helpful, but it may be better to place them under the muscle.

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

Breast Augmentation/Lifting Concerns, Risks/Complications, Need for Revisionary Separation??

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Thank you for the question and pictures. Although it is not possible to provide you with a specific analysis  and advice, your question touches upon some of the issues surrounding breast augmentation/lifting surgery.  I am hopeful that the response will be helpful to you and patients considering augmentation/lifting surgery in the future.

 Patients who are considering breast augmentation/lifting surgery should understand that this combination surgery is significantly more complex than either one of the procedures done separately. In other words, the combination breast augmentation / mastopexy surgery differs from breast augmentation surgery alone in that it carries increased risk compared to either breast augmentation or mastopexy surgery performed separately. Furthermore, the potential need for revisionary surgery is increased with breast augmentation / mastopexy surgery done at the same time.  This revisionary rate may be as high (or higher) than 20%. Patients should be aware of this higher revisionary rate;  obviously, the need for additional surgery, time off work/life  considerations,  and additional expenses  our “factors” that should be considered before undergoing the initial operation. I would say that, in most communities,  anesthesia and surgery facility fees (minimally) are patient responsibility,  when returning to the operating room for revisionary breast surgery.

 Personally, I find that the breast augmentation/lifting procedure to be one of the most challenging  of the breast operations I perform, even compared to somewhat complex revisionary breast surgery. On the one hand,  when performing breast augmentation/lifting surgery we are increasing the breast  size with breast implants;  on the other hand, we are reducing the breast “envelope” in order to achieve the breast lift. These two “forces” must be balanced as perfectly as possible in order to achieve the desired results. Removing too much skin/ breast tissue is problematic;  removing too little breast skin/tissue can also be problematic.  Remember also that patients presenting for breast lifting surgery and general have lost some skin elasticity/thickness making potential incision line healing problems and/or recurrent drooping/sagging important concerns to communicate.  The analogy I use in my practice is that  of a thinned out balloon,  being expanded with additional air; I hope that this analogy helps patients understand some of the issues at hand when performing the combination breast augmentation/lifing operation.

To achieve  a surgical result where the breast implant and breast tissue “come together” and behave like a single breast is one of my goals but can be difficult to achieve.  Essentially, we are trying to create a breast implant/breast tissue interface that feels and behaves as naturally ( as a single unit)  as possible. Generally speaking, making sure that the breast implant has some sub muscular and some sub glandular component ( dual plane)  and tailoring the overlying skin/subcutaneous tissue/breast tissue as precisely as possible over the underlying breast implant is key.

Despite these efforts, breast implants are after all a foreign body that don't necessarily stay where we wish they would;  therefore, breast implant related problems such as positioning ( too high, too low, lateral displacement etc.) can occur  and may be a reason for returning to the operating room for revisionary breast surgery.

I use a “tailor tacking” technique that allows a determination of what breast implant should be used to SAFELY produce the results the patient is looking for. This technique involves use of a temporary sizer and temporary “closure” of the overlying breast skin over the sizer. 

The use of the tailor tacking technique is very helpful.  Breast lifting involves removal of skin ( and tightening of the breast skin envelope)  while breast augmentation involves expansion of the breast skin envelope. These 2 forces are counteracting each other. Therefore, it becomes important to remove the appropriate amount of breast skin and to use the appropriate  size/profile of breast implants to balance these 2 forces appropriately and to allow for achievement of the patient's goals while minimizing risks of complications.  Again, despite these efforts, breast implant and/or tissue/skin complications may arise causing minor or significant complications.

 Generally speaking, it is difficult to achieve the “perfect” result with breast augmentation/lifting surgery, despite best efforts.  Patients should be aware of the complexity of this combination procedure, achieve REALISTIC EXPECTATIONS prior to proceeding, and understand that additional surgery ( along with the additional recovery time, stress, expenses etc) may be necessary in the short or long-term. Patients should understand that the results of the procedure will not necessarily match aesthetically the results of patients who have undergone breast augmentation surgery only.

For example, some patients who wish to maintain long-term superior pole volume/"roundness" may find that this result is not achieved after the initial breast augmentation/lifting operation.  An additional operation, possibly involving capsulorrhaphy, may be necessary to achieve the patient's longer-term goals ( with superior pole volume/roundness).  It is helpful if patients understand that this breast implant capsule used to provide the support for the breast implant is not present during the initial breast augmentation/lifting operation.  The capsule (layer of scar tissue) forms around the breast implant and may be a good source of supportive tissue during revisionary breast surgery,  Including correction of breast implant displacement/malposition problems ( such as bottoming out, symmastia,  lateral displacement etc).

 Potential risks associated with breast augmentation/lifting surgery include infection, bleeding, incision line healing problems, loss/change of nipple/areola complex sensation, and blood flow related issues  to causing skin or tissue necrosis.   Poor scarring,  pigment changes, areola/nipple asymmetry etc. are also potential problems. Again, patients may experience implant related problems such as encapsulation, leakage, displacement problems ( too high, bottoming out, lateral displacement, asymmetric positioning etc.), rippling/palpability of breast implants etc.  Patients may also be dissatisfied with breast size, shape, and/or how the  breast implants and overlying breast tissues “interface” with one another.    Occasionally, a breast implant may even have to be removed and the patient will generally be “implant free” for several months at least.  Obviously, this situation can be quite physically, emotionally, and psychosocially stressful to the patient involved.

Given the complexity  of the combination breast augmentation/lifting operation and the greater risk of revisionary breast surgery needed, there are good plastic surgeons who will insist on doing the procedures separately.

For me, if I see a patient who needs a great degree of lifting, who has lost a lot of skin elasticity, or  whose goal is a very large augmentation then I think it is best to do the procedures in 2 stages (in order to avoid serious complications). However, doing the procedure in one stage does increase the risks of complications in general and the potential need for further surgery. This increased risk must be weighed against the practical benefits of a single stage procedure (which most patients would prefer).

Conversely, if I see a patient who requires minimal to moderate lifting along with a small to moderate size augmentation (and has good skin quality), then doing the procedure one stage is much safer. Nevertheless, the potential risks  are greater with a 1 stage  procedure and the patient does have a higher  likelihood of needing revisionary surgery.

Having discussed some of the downsides  and potential risks/complications associated with breast augmentation/lifting surgery, most patients (If properly selected and who are doing the operations at the right time of their lives  psychosocially) accept the scars associated with breast augmentation/breast lifting surgery as long as they are happy with the improvement in contour, size, and symmetry.

 I hope that this summary of SOME  of the issues surrounding breast augmentation/lifting surgery  is helpful to you and other women considering this procedure in the future.

 The attached link may also be helpful.

 Best wishes.



Sagging After BL and BA?

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A before posted photo would demonstrate the nice result you have! But you did not post a before photo. Re operation can be done but you need to consider realistic expectations. 

Breast lift and implant question

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It looks like you also had arm lift and lateral trunk lift as well. You have healed well and have had what happens with big implants above the muscle with poor skin quality. The number one operation in the world is a silicone implant above the muscle and it works just fine as long as the skin is good and the implant not too big. I think a  smaller implant is a good idea and you may need some internal additional support using a tissue matrix. Your doctor sounds like he or she is trying their best by not having you pay a surgery fee. Good Luck!

Gregory T. Lynam, MD
Richmond Plastic Surgeon
4.9 out of 5 stars 60 reviews

Sagging After BL and BA?

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Very large implants held by skin that has lost its strength and elasticity will pretty much always result in your current problem. As to costs of revision, that will vary with each surgeon and should have been spelled out in the paperwork you received before the surgery. Retightening bad skin and sticking with extremely large implants and expecting a different result is not realistic.

Ronald V. DeMars, MD
Portland Plastic Surgeon
5.0 out of 5 stars 28 reviews

Breast Lift and Breast Aug

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The combination of breast lift and breast augmentation is complex. This is especially challenging when combined with poor skin elasticity as is seen after massive weight loss and when larger than 350 cc breast implants are used. Revisions are common in this situation. I discuss this before surgery with all my patients, including future costs and timing for further intervention.

Specific recommendations for treatment can only be made by a plastic surgeon who has available a full medical history and who has performed a physical examination. Before pictures are also needed. The scar extending up to the armpit suggests there was more going on that the typical breast lift with the addition of breast implants. You may benefit from additional in-person consultations to review your options.

Joseph Mele, MD
Walnut Creek Plastic Surgeon
4.5 out of 5 stars 17 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.