What is the best way to fix over-dissection of pockets? (Photos)

Thanks for your question, & including your photos! In my experience of doing thousands of breast augmentation surgeries, I’d favor a mix of internal capsulorhaphy, using both strong internal permanent Sutures, & a “popcorning” method. I don’t usually use ADM for people with your situation, although some surgeons do. Best of luck to you!

Your
breasts were asymmetrical in volume, shape and position pre-operatively.  Also, your nipple-areola complex was aiming
outwardly and the breasts are widely separated. 
Simply adding implant would not solve the problem.  The surgeon centered the implants under the
nipple-areola complex resulting in lateral dissection and displacement.  Using a passive technique such as GalaFlex or
suture will improve your lateral displacement but will not correct the
asymmetry or direction and position of the nipples.  I recommend a modified Benelli approach.  Using a circumareola incision, your breast
tissue is reshaped creating upper pole fullness, elevated higher on the chest
wall and more medial to increase your cleavage. 
At the same time, smaller implants can be replaced in the retro-pectoral
position, rather than subfascial.Best Wishes,Gary Horndeski, M.D.

Also known as capsulopexy, I sew off the capsule with a permanent suture.   Usually this fixes the problem.  With a biologic, the challenge is still that you have to have good purchase on the chest wall.  If I can get that without a biologic, there is one less step (and expense!) involved.Good Luck!

Hi AlexandriaInTexas,

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, MHA, MS

Certified, American Board of Plastic Surgery

Member, American Society of Plastic Surgery

Member, American Society of Aesthetic Plastic Surgery

Good morning!We have already spoken personally via email, but I applaud your research- that's the best way to make sure you get the correct repair by the correct revision specialist!

Hello Alexandria,
Having just sat on a panel on this exact topic at our national meeting, I can tell that there is not likely a "best" way.  The options include: cauterizing the capsule ("popcorning"), suturing the capsule (capsulorraphy) and cutting the capsule and resuturing (partial capsulectomy and capsulorraphy).  In my hands, the last option tends to work the best but all three surgeons on the panel were able to show great results with their technique.  It is probably most important that you and your Plastic Surgeon agree on both a plan and the restrictions in the postoperative period.  In particular, if your implants are under the muscle, there is a higher risk of implant displacement if you return to activity too soon.  I typically suggest 6 weeks of no lifting/pushing/pulling over 5 lbs.  
And I agree that since the implants look like they are an appropriate size for your body, that the mesh is unnecessary.  Sometimes more is just more.  
Best of luck.

A topic near and dear to my heart... fixing implant pockets! First, let's give also say that your right implant is riding a little high in your photos and causing asymmetry (the left breast in the photo for all you non-PSs). Your left shoulder is also lower in all the photos. You may want to take and check the photos again with your shoulder straight, or maybe you are permanently like this and therefore we should make the implants straight with your shoulders crooked! I don't see that in your pre-op tho... so check it out. If the pocket was large when the implant was put in (ie within three months of surgery) then fix with lateral capsullorhaphy sutures. The lateral too big part is oversewn and then the implant is forced to sit more medially. If the implant pocket stretched over years put it in and internal dermal matrix bra. Used for reconstruction, this is my "go to" for all difficult pocket situations, as it is indestructible, reliable, and lasts forever.Also sub-fascia may be BS as some people have thin fascia and it does very little to hold, cover, or prevent cap con, and acts as a submammary implant after all.

capsulorrhaphies are needed at minimum.  Your photos do no show anything abnormal but a photo on your back would have been helpful here.  ADM can also be added but I try to avoid and use your own tissue first and ADM if we have to come back later due to failure.  The post op regimen is strict and you must wear a underwire bra 24/7 (yes, in the shower too) for 6-8 weeks and if a nerve is caught in the suture repair, your pain will be more significant and last longer.  Activities are restricted as well for the duration of bra wearing so you must be able to devote time and commitment to this to have a good outcome.

Thank you for the question and pictures. Internal suture repair of the breast implant capsule ( capsulorrhaphy) will be necessary to prevent breast implant displacement and better center the breasts on the chest wall.  In my practice, this repair is done with a 2 layered permanent suture technique. The use of acellular dermal matrix is an option (although not usually necessary)  especially if significant implant rippling/palpability is present.
During the procedure, the capsule close to the sternum may need to be opened as well ( reverse capsulotomy). Depending on your goals and measurements, changing breast implants may or may not be necessary.
 I generally suggest patients wait at least 6 months before undergoing this type of surgery. In my opinion, the more developed/stronger the breast implant capsule, the better the repair ( sutures “hold” better).
 I also think that postoperative management is very important in  achieving successful results after this type of surgery. I advise my patients to keep their elbows by their sides as much as possible for several months after the procedure is performed.
 
 Best wishes.

Hi and thanks for your question.Unfortunately, your pics only reveal to me some minor to moderate asymmetry, much was preoperatively present.  I wish you had pics of you lying on your back.In any event, based on what I can see, and without formal exam, I would start with a capsule revision which would include a incising the capsule where indicated and "imbricating" the capsule (suturing it to modify the pocket to move the implant to proper position).I don't see a reason to use mesh, and the size of the implants is relative and they don't appear too large on YOU!Hope this helps.sek