Silicone and Fat Grafting. How Can a Double Bubble Occur on Day of Surgery? Why Was It Not Fixed Immediately?

I cannot believe I am experiencing everything I tried so hard to avoid! I went to what I thought was the "best boob doctor" in Boston - great reviews, pioneer in research/teaching/methods etc. When I woke from surgery I saw the "dent" in my left breast- it is now in both. I am 32, had 375cc silicone, under with fat grafting over them. 4wks postop. I know it is early, PS blew it off at day 5, afraid he is going to blame my body. They look horrible! Scars horrible. What am I supposed to do?

Doctor Answers 10

Uneven breasts after breast augmentation

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Without seeing before photos and knowing what exactly was done at surgery it is hard to know how/why you got this result. Your concerns however are quite valid. I am curious where the fat was grafted and why it was grafted. Your implants were presumably placed via armpit incisions. The photos show high implants with possible incomplete disruption of the chest muscles near the breastbone and possible disruption of the inframammary folds. The risks of this happening are greater with an armpit approach than other approaches especially when the surgery is not done endoscopically.

The main question is what do you do now. It is obvious you will need more surgery and this will require an incision on or under the breasts. Timing of the next procedure is debatable. I do not think you need to wait 6 months but you will need to be very diligent in choosing another surgeon.
My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.

Los Angeles Plastic Surgeon

Your inframammary fold is distorted

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Your breast augmentation was transaxillary with silicone gel implants. This approach is more prone to the implant malposition and fold distortion. You will need revision with inframammary incision. Your doctor should take care of the problem. Give him time and let him know your concerns. If he refuse organ not help you get second opinion.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.7 out of 5 stars 153 reviews

Poor looking breast augmentation

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I would agree that you have a poor looking result at this point.  It would have been very helpful to have seen your preop photos though to see what your body brought to the table.  You are afraid he is going to blame your body, but in truth, some people's bodies do have starting points that predispose to more difficult surgery and more potential problems.  A truly experienced surgeon, in my opinion, has the time tested judgement to see those problems coming before they happen and can steer you towards procedures and implant choices that may minimize the risks your anatomy poses.

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Silicone plus fat grafting

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It   looks like    that  you had   a tuberous  ptosic   breast    before  your  surgery   ,   because     of  apparence  of the distance of  your nipple  and  because   of the  double bubble that   you are  presenting   now .

The  armpit via  incision   is  one   of the  worst    when    you   have    this type  of condition,    for many  reasons   first   because   the  incidence  of  pocket assymetry  and  because   constricted breast that  needed to be    radiated during   surgery to  make  spread the tissue  ,   and  give    the   breast   a rounded  apparence  ,.  the  sense   of   the   graft ,    for  me   make  no sense  at  all  .Now     you    have    some deformities   that    you   should  make   the  correction with a reintervention.  just   be  patient   wait  your   time ,   and    wait   for  a  decisition   at  least  6 months  to one year.

Cynthia Disla, MD
Dominican Republic Plastic Surgeon

Breast augmentation with fat grafting

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Having just return from the anesthetic meeting in Boston, one of the discussion which generated great interest was the addition of fat grafting to breast augmentation.  Obviously there are differing opinions on its use and indications. As mentioned by others, unfortunately you did not include preoperative photos, but I can extrapolate backwards from your postoperative pictures that you probably had some mild ptosis with loss of fill. Generally speaking an inframammory approach, which would allow for gentle release of the inferior breast and pectoralis muscle though a biplanar technique, would have allowed for upward rotation of the nipple areola complex so that you would see more inferior breast on the frontal projection. 

What you are seeing is not in fact a double bubble caused by the implant (because they are sitting in a superior position), but probably the fat grafting that was placed in an attempt to create more inferior breast tissue.  A transaxillary approach, which I seldom use anymore because of the higher need for revision, is a difficult choice when there is significant need for release of the inferior breast at the level of the inframammory crease; even if preformed endoscopically. 

At this point in time, hopefully some of the fat will reabsorb, but you will require a revision to lower the prosthesis. As with any new technique the appropriate use of fat grafting in breast surgery has yet to be determined. It certainly makes sense in contour defects with breast reconstruction, thin tissue areas or in revisions of some cosmetic procedures.  You need to communicate your concerns with your surgeon so that the proper revision can be performed and satisfying result achieved. 

Silicone Implants and Fat Grafting

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Thanks for posting after pictures.  It would be best if you could post before pictures as well.  More clinical information would also be useful as to why would have fat grafting at the same time as implant placement.  For primary breast augmentation, this would be very unusual.  Additionally, as others have stated, axillary placement in general and with silicone specifically has more complication issues than traditional infra mammary fold placement.  From your photos, it appears that you will need a revision surgery and I would suggest a infra mammary incision.  Many people think that trans axillary incisions hide the incision, but your case in point shows that this is not always the case.  Rest assured that improvements can be made and even if you do not have a revision surgery, you may see improvement over the next few months as the implants settle.


Good Luck.

Silicone breast implants with fat grafting

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What to do after a poor result with silicone gel breast augmentation? For those considering augmentation the lesson hear is to look to more that one opinion, and when things don't seem right keep looking. Fat grafting with augmentation, really? Great reviews, do your own homework. For now you can wait to see if the skin envelope relaxes and wear a firm under-wire to help 'set' the fold, or consider a revision. The scar under your arm will sort out alright, but if revision is needed your surgeon will need a periareolar or breast fold approach for access to suture the double bubble.

Best of luck,


Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Double bubble

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Yes, it looks like yoiu have a double bubble.  Preop photos would be nice to evaluate your breasts.  Did you also need a lift?  Hard to say from the photos.

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

Silicone and Fat Grafting. How Can a Double Bubble Occur on Day of Surgery? Why Was It Not Fixed Immediately?

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Sorry for all your issues and great photos posted. I agree without before photos very hard to advise or even answer your questions. I can assume you were slightly ptotic or droopy. Selecting the transaxillary incision with silicone implants of that cc size has a higher malposition rate, so that answers the double bubble effect. Also under the muscle placement from the transaxillary incision does not allow adequate inferior and medial dissection, another reason for the double bubble effect. As to why this was not addressed while in the operating session? Only your chosen surgeon can reply to this. Also fat grafting in the superior poles, interesting idea but was it really necessary? My guess without seeing before photos was you needed a donut lift at the minimum. Maybe a L-shape lift, better release of the infero medial pectoral muscles. And since fat grafting was being done why not place some in the area of the "double Bubble"? Finally your options are further revisional surgery. 

Breast augmentation

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In general the further away the incision from the breast the higher the complication rate, that is true for the axillary and umbilical incisions.

Your double bubble need revision surgery, it will not correct in time.


many surgical options available for you. take the operative note with you to the consult because implant size and position is important to know

Samir Shureih, MD
Baltimore Plastic Surgeon

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.