At five months postop the implant position is not likely to change significantly. The fibrous capsules that naturally form around any implanted medical device are now well-established, so while I am sure it is not what you prefer to hear, it almost certainly will require a revisional surgery to improve your breast shape and to achieve a more aesthetically ideal positioning of the nipple-areola complexes (NACs). To provide a complete and accurate assessment of your current situation, one would need to review your preoperative photographs as well as some additional information (implant position relative to the pec major muscles, type of dual-plane dissection if performed, implant size and profile, etc), and of course perform a physical examination. You stated that you had ‘low nipples to begin with’, so clearly there was some element of preoperative ptosis (the medical term for droopiness, the ‘p’ is silent). From the photos it appears that implants which are too projecting - and perhaps too large - were placed in too high a position. In profile this creates an unnaturally full upper pole (excessive roundness / projection in the cleavage area), and in the lower pole the appearance of a breast hanging off of the lower end of the implant. If the implants are subpectoral, an incomplete release of the inferior origin of the pectoralis major muscles may hold the implants in too high a position and contribute to this appearance. Patients with mild to moderate breast ptosis who seek breast augmentation with implants generally fall into three categories, which vary with the degree of breast ptosis and the degree of skin elasticity: 1.Will have a fairly ideal appearance with an augmentation alone, as implant pocket dissection and implant placement can be performed in a manner the rotates the NACs into a higher position on the breast mound (usually requires a conservative implant volume or the upper poles will appear too large/full).2.Will have an acceptable appearance overall with augmentation alone but the NACs will be relatively low on the breast mound; many moms of 2 or 3 are fine with this, as are patients who are absolutely opposed to breast lift scars (again implant volume should be conservative).3.Will have the appearance of breasts hanging off of implants and therefore absolutely require a mastopexy at the time of augmentation.Without reviewing your preop photos (and, more importantly, without actual physical examination), it is difficult to say with certainty what set of circumstances led to your current postop appearance. But from your photos and your description I think it is most likely that preoperatively you fell into category 1 or 2 above, and that your postoperative appearance at five months results from overly projecting, overly large breast implants being placed in too high a position. It sounds as though preoperative Vectra imaging led you (and perhaps your surgeon) to believe that the ultimate NAC position would be more aesthetically ideal. That is a problem inherent in computer imaging: it shows you a potential or possible result, but not necessarily the result that you will actually end up with. What you get depends on what happens in the operating room. Breast augmentation of the mild to moderately ptotic breast, without simultaneous mastopexy, is a surgical procedure that requires careful preoperative planning, thoughtful and usually conservative implant volume and profile selection, and meticulous attention to detail in the OR. It is also incumbent upon the surgeon to provide each patient with a clear understanding of the outcome they are likely to have. Rather than showing patients a computer-modified image of what they might look like postoperatively, I find it much more useful to show patients ‘before and after’ images of actual surgical results where the preoperative appearance was similar to their own. This gives prospective patients a more meaningful impression of the kind of result they can expect depending on their own starting point. Your surgeon wants you to continue to wear a breast band for postop months 6 and 7 then return to the office for re-evaluation. If you have confidence in your surgeon based on your experience thus far, then wait it out and return at 7 months postop. If the appearance has not improved, then ask your surgeon what their plan would be for surgical revision. If you have lost some confidence, or if it would just provide you with some peace of mind to hear what someone else has to say, then it is probably worth seeking an opinion from another surgeon who is experienced in breast augmentation and breast augmentation revision surgery, and who has a large number of ‘before and after’ images for these procedures which show results that are appealing to you.
