1 year post op - Bottoming out, implants far apart and cleavage gone. What implants would be best for a revision? (Photos)

Question

1 year post-op. Doctor has agreed to do a revision (given the bottoming out on one side) and agrees we can change implant size tbut no decision made about sizing of new implants. I’m unhappy. I feel like both have bottomed out, right side more. I also feel like they could have been placed closer together. Implants really fall to the side when I lay down. The implants also took away natural cleavage line, I feel like because they are pulling to the sides, my cleavage looks even flatter than before and they’re just not lining up with my anatomy. They look unnatural. I also feel like they look like two small round balls that are far apart and I’m thinking I need larger diameter implants. I cannot decide on size and need second opinion. These are Allergan Natrelle Inspira 165 low plus profile which have a base diameter of 10.50 cm and projection of 2.7. I am 41 years old (no kids) 114 lbs, 5’5, I wanted a very natural result and did not want to go too big. Should I stick with with low plus profile but go bigger 190 (11.00 diameter and 2.8 projection) or 205 (11.50 diameter and 2.9 projection) or do I need even more? Should I try low profile instead of my current low plus? Please help me get a more natural result.

Mehmet Ozdemir, MD · Answer

I truly empathize with your frustration, as it’s clear that the current implants aren't harmonizing with your natural anatomy, leaving you with that "separated" look you're describing. The core of the problem is that a 10.50 cm base diameter is simply too narrow for your chest wall, which creates a wide gap in the center and prevents any natural cleavage. To achieve a more integrated, natural result, you need an implant with a wider "footprint" to fill the width of your breast pocket; moving to at least the 11.50 cm diameter (the 205cc) would be a significant step in the right direction to bring the medial edges closer together. However, increasing the size alone won't solve the "bottoming out" or the implants sliding to the side when you lie down. For this revision to be successful, your surgeon must perform a capsulorrhaphy which involves internal sutures to tighten and reinforced the lower and outer boundaries of the pocket to physically "lock" the new, wider implants into a more centered and stable position.

Robert M. Lowen, MD · Answer

Dear Diligent,  we will assume your present picture is the second from last on the right and compare you to yourpre-op picture.  The anatomy is widely spaced breasts, no soft tissue coverage over the sternum.
  After the initial augmentation, the pockets are both over-dissected and there is little strong support for an implant, inferiorly and laterally. After the re-augmentation, the incision  is 2-3 cm above the inframmaary fold, so the lower pole skin is stretched out.  The issue of lack of soft tissue coverage medially is aggravated by the Implants being inferiorly and laterally displaced,  one of then hardest combinations to correct.  1.  You can't get soft tissue coverage where it does not exist without adding it in some form,  for example, fat grafting or regenerative fat tissue like alloClae. 2. Your existing pocket will not easily resist stretching out again, even with the small size implants you are considering.  The result can never look "natural" because the edge of the implant cannot be concealed, and the bigger the implant, the more demarcated and separate the implant willl look from your chest.  To mitigate these problems, a surgeon has several strategies. 1. Correct the malposition with a new neosubpectoral pocket if the implants are partially under the muscle.  A neosubpectoral pocket dissects a new pocket, tacking the old one down to the chest wall and not depending on suturing the old pocket tighter,  which does not hold very well, and is likely to recur as it appears have done here.  To that neosubpectoral pocket,  some synthetic mesh like galaflex, or acellular dermal matrix reinforcement can make the repair stronger.  What you do not want to do is solely rely on a wider implant to fill the area between the breasts and give more cleavage.  That risks over dissecting medially, disrupting the pectorals medial origins and getting an animation deformity or symmastia.
    In summary, centralize the implants through a dependable method, e.g. neosubpectoral pocket, or capsular flaps with mesh reinforcement, and augment the soft tissue envelope with fat grafting, or lacking fat, if you are too thin, considering one or more sessions of placement of alloClae, or even Renuva.

Daniel Barrett, MD · Answer

Dear Diligent984156,

breast revision surgery is the most difficult plastic surgery procedure performed. Botched breast surgery alters normal tissue planes and laxity, the ability of breasts to heal properly, and leaves scar tissue that dramatically affects the level of difficulty of the corrective surgery.
Many patients come in to correct poor outcomes from their initial surgeries. The most common problems are due to implant malposition, bottoming out of the implant, poor scarring, and incorrect implant size.
While the type of revision required will depend on the result of the previous surgery and the desired result of the patient, some revisions involve extensive pocket repair that may or may not need specialized external bras.
If you are considering breast surgery revision, you should speak with a board certified plastic surgeon and have yourself properly assessed. Only after a thorough examination you will get more information and recommendations. Also, you have to make sure that your surgeon understands your breast augmentation goals.

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

Gary M. Horndeski, MD · Answer

You will need the implants removed through a circumareola approach to elevate the nipple-areola complex higher and more medial. The pockets must be plicated or restricted laterally and inferiorly to push the implant higher. Slightly larger implants will help as well.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Jacob Carlson, MD · Answer

Thank you very much for submitting your pictures and details of your procedure. You had mentioned that you currently have Allergan Natrelle Inspira 165cc Low Plus profile implants. Were these implants placed on top of or underneath the muscle?
I would agree with your assessment that you have experienced some bottoming out, so some pocket work may help move the implants into a better position on your chest.
Aside from the implants falling out to the side, what else would you want to change about the appearance of the implants? Would you make any changes to the: amount of cleavage, upper pole fullness, projection, size?

1 year post op - Bottoming out, implants far apart and cleavage gone. What implants would be best for a revision? (Photos)

Answers (5)

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