Your Questions

Q: Dr. Eppley, I am interested in breast implant revision. I had 375cc filled to 425cc saline over the muscle implants placed 20 years ago. I got them after the birth of my first child. I went on to have 4 more children and breastfed all of them. I am 5’4″ and 130 pounds. I feel best at 110 pounds but the rippling of the saline implants is terrible and embarrassing at that weight. I would really like to lose weight, deal with the rippling and switch to silicone implants. Was hoping to increase size to 525-625 if possible. I am worried about animation deformity with under the muscle. I do not like that possibility at all. Can it be avoided? The doctor’s here are very conservative size wise and the ones I have consulted with do not like or offer silicone. They did say switching from over to under would be an very easy procedure but I would like to avoid saline implants. One Dr  from several states away recommended fully under muscle implants. Didn’t even know that was possible. Another recommend acellular matrix grafts with silicone under muscle to minimize but not eliminate any visible movement. Have heard great things about your work and would really appreciate you opinion and ideas on what can be done.

A: Thank you for your inquiry. Let me help clarify all of the breast implant revision options you have presented as they cover every single onethat is available. First of all, the shape of your breast mounds and position of your nipple-areolar complexes are extraordinarily good for someone who had had four children and breastfed them after the original breast augmentation procedure. It is very rare to find someone with your history that does not need a major breast lift at this point. So the approach of simply changing breast implants is a viable one for you.

There is no question that you want to switch to silicone implants. I am shocked to hear that in your area they don’t use silicone breast implants. In contemporary breast implant surgery saline implants today make up less than 25% of implants used and are only used because of their lower costs. They are are inferior implant in regards to feel and longevity compared to silicone implants. While silicone implants will not completely eliminate all rippling, they will go a long way to eliminating the majority of these palpable and visible implant folds.

The next issue is that of either keeping your existing implant location or switching to an under the muscle location. You have essentially decided that already in that any under muscle location will cause an animation deformity. That is an unavoidable issue since most submuscular positions are really partially under the muscle and the side of the implant is only right under the skin. Thus when the pectoralis muscle moves the implant is ‘unchecked’ at the side and it moves in that direction. Maneuvers such as placing ADM grafts to totally cover the implant edge or moving muscle from the side of the chest wall up over the implant can be done to reduce/eliminate that problem. However, increasing the implant size to 600cc makes making a complete submuscular pocket impossible. (implants are too big to get full muscular coverage) The use of ADM grafts is an option for coverage but that will add over $6500 to the cost of surgery for implant cost and time of placement, exponentially increasing the cost of breast implant revision surgery.

I see no problem with switching your existing implant size to 600cc plus, but as you can see you can not have everything that you want. (no animation deformity, no visible rippling, reasonable costs) Thus what I see as the most acceptable option for you to go with a high profile, round smooth silicone implant that remains in your current subglandular position. I prefer the submuscular position almost always and the animation deformity may not be that significant but that may not be risk that is appealing to you

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast augmentation revision. I had breast augmentation three years ago. Right after I had major issues with my right breast implant.  It was smaller and now moves around a lot, almost like its not even in place now. In addition, it is painful. My previous surgeon went through my armpit to place them and whatever he tied his suture to it is no longer attached. And he doesn’t see an issue after multiple visits.  I just want to cry. I have decided to move forward and have heard multiple positive reviews from patients that came to see Dr. Eppley.  Very excited to see the light at the end of the tunnel!!!

A: It is hard to tell based on your description as to the exact nature of the problem with your right breast implant. Besides being smaller and moving around more, the source of the pain is not clear. Usually pain with breast implants is associated with either a tight pocket, capsular contracture or a ruptured silicone implant. I am going to assume that since your implants were placed through the armpit that they are saline implants.

Regardless at least a right breast implant revision is going to be needed. That will have to be done through a new inframammary fold incision. You talked about ‘ a suture that was tied that is no longer attached’ but such an entity during transaxillary breast augmentation surgery does not exist so that is an irrevelant issue. The question is whether this is a pocket adjustment with more volume added to the existing implant or whether a new implant is needed. This will require a physical examination to determine exactly what needs to be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I believe that one of my breast implants is leaking. I have saline, below the muscle and I have had them about 13 1/2 yrs. The size is fine 38D. I know I need to replace the leaking one  but is there some reason why I should mess with the left one, because it is the right that is leaking. And I don’t think I want to switch to silicone, because I heard they are not good for you if they burst and  I don’t think they feel as soft. Is the saline leak harmful?

A: Th saline leak is not physically harmful. While you can just exchange the  deflating breast implant alone, most patients choose to do both sides as they fear that the other side will soon develop a leak also. That is just a personal choice one of surgical opportunity and preventative maintenance.

Your perceptions about silicone implants is not accurate. They are perfectly safe, they can’t burst or deflate and actually feel more natural than saline as they don’t have of the rippling effect that many saline implants do. While silicone implants can develop a rupture, they are composed of very cohesive gels that act more like solids than liquids. Thus the concept of a leaking silicone breast implant is not accurate, it is a rubbery formed jelly that just sits there inside the surrounding capsule that you body naturally forms. This is why silicone breast implants do not deflate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have silicone breast implants which have hardened from lack of sex and age of implants. What can be done to get them replaced and have nice soft breasts again?

A: Many old silicone breast implants originally placed in the 1980s are very firm today due to capsular contracture. There are many reasons why these old implants have this aesthetic pathologic condition, from gel bleed to implant ruptures, but there is no scientific evidence to correlate a lack of sex as one of them. While massage of breast implants was preached as a necessary technique to prevent capsular contracture back then, this is not needed today. The best approach for your implant problem is to have them removed, perform total removal of all surrounding breast scar/capsule (which often shows signs of calcification) and have new breast implants placed under the pectoralis muscle. While the cause of breast implant capsular contracture is still not fully understood even today, what is known is that an under the muscle implant position (submuscular) is much better than on top of the muscle (subfascial) for prevention of it developing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast enlargement when I was 20 years old and I was suppose to get a 36 full c and I got a 36 DD and I have never been happy with it and Im 44 years old now and I want them to be smaller. It makes me look like a bigger person and I want to be able to look smaller and wear tops that are smaller can you help me please. It has me in a bad depression and I have a complex now and I don’t even like to look in the mirror anymore. Thank you so much.

A: Exchanging breast implants to a smaller size is very straightforward and much easier on you than the original surgery since there is an established breast pocket. It would be helpful to know what type (saline or silicone) and size (cc volume) your current breast implants are. To go from a DD to a C would need at least a 150cc volume reduction if not more depending upon your body and chest wall size. The key question in your breast implant revision (downsizing breast implants) is what will the enveloping breast skin do. In most cases, significant downsizing of breast implants may require the need for some form of a breast lift or skin tightening. This, of course, depends on what the breast tissue was like before surgery and how much elasticity remains in your breast skin currently.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had breast implants placed, 500cc silicone gel implants placed under the muscle, four months ago. After surgery my right implant was seen to be lower right after surgery and it stayed that way. Then three weeks ago, I had the implant revised and tucked up higher. I am concerned now as it doesn’t look right. The bottom part of the revised breast looks square like a straight line across the bottom. It does not look like the other side. Attached are some pictures of my breasts before and after. What do you think?

A: Let me share with you some general

thoughts about the type of breast implant revision that you had. Unfortunately breast implant asymmetry is not rare, averaging around 5% to 7% in most practices. It can be caused by the patient’s own pre-existing breast asymmetry (often unrecognized), over dissection of the implant pocket, disruption of the IMF (inframammary fold) ligamentous attachments or stretching of the pocket due to the weight of the implant. Regardless of the cause, bottoming out of a breast implant is more of a challenge in which to have a successful revision than when the implant is too high. This is because a new IMF must be established and then it must stay stable as it heals. Inevitably when the revision is done, the bottom pole of the breast and its new fold level is rarely going to match perfectly with the other side. Some plastic surgeons prefer to set the new IMF at the horizontal level of the other side, others choose to make it higher with the expectation that there will be some rounding of the lower pole of the breast as it heals and settles. Either way, the new fold will often look like a straight line rather than a rounded curve like the other side. This shape is often unavoidable. Whether it will round out somewhat or stay the same is impossible to say at this early point. It is going to take up to 3 months to see how its shape evolves. What matters most at this point is that the horizontal level of the implants are fairly even. If that stays that way then it would be best to leave it alone. While that may not be the ideal shape you want, further efforts at manipulation may cause other problems (longer scar, infection) that may not be worth the risks and trade-offs.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had a breast enlargement in September under the muscle. Three weeks ago I had to have revision surgery as my right breast dropped and now my breast still does not look right as he has tucked it up so tight the breast looks square. I would really appreciate if I can send you the photos and you can give me some advice and tell me what your thoughts are. Many thanks.

A: Unfortunately breast asymmetry after augmentation surgery is not rare. While one implant can be too high or too low, the more challenging revision is when the implant is lower than desired. It is always easier and more predictable to drop an implant down than it is to raise it. This is because the new lower breast fold is held together with sutures and it is not always known how stable the new fold position will be with time. Ideally I prefer to position the new breast fold in the desired position and use enough permanent sutures that it does not drop or settle later. Other plastic surgeons prefer to overcorrect with their experience that some dropping of the implant will occur as it heals.

Based on your present description of a square-shaped implant, that would suggest that the new breast fold is higher than the other side. Given that it is only three weeks after your breast implant revision, it is too early to say what will happen in the next few months. You need to give this revision time to heal and settle for at least 3 months if not longer. Any attempt at further revision now would be ill-advised.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had my saline implants since 1997 and my pockets have stretched. I am looking for breast revision. I’m interested in the techniques used along with before and after pictures.

A: When you refer to having your breast implant pockets stretched, I will assume that means your implants have both dropped (too low) and are even too far to the sides. (particularly when you lay done) Revision of your breast implants by etightening the implant pocket (making it smaller) is done by two fundamental techniques. The most common method is to remove part of the inferolateral capsule and tighten the pocket and lift the implants into a higher position using permanent sutures. This will be successful in the majority of cases. In patients that fail this method or have very thin capsular tissue and overlying skin, the entire lower breast pole may be supported by a sling of allogeneic dermis to provide the necessary lower pole support. This is not a first choice method due to the high costs associated with it although it is commonly used in breast reconstruction because insurance pays for the material. (the dermis material alone can cost anywhere from $4,000 to $6,000)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got breast implants one year ago an am not happy with the size. They are too big. They are only 175cc but they are just too big for me. In exchanging the implants to something smaller, I am not sure what size implant to change to In reading around online, there is much discussion about the base width diameter of the implant like its the holy grail, even though, interestingly, opinions diverge. Some say stay the same implant diameter and no larger, a bit larger, can be smaller by up to one cm, thin women should have smaller, and on and on…. so no hard-and-fast-rule it seems. But 8.2 cm (diameter of smallest available 100cc implants) to my 10.5/11cm change does seem a lot, if base width diameter is typically a consideration that you guys seem to have strong opinions on. I recognize that results are harder to pin down than one might wish, but why do you think that’s better than 130’s with a 10cm diameter, or 125 mod-plus with a 8.9cm diameter, in my case? Related to that, do you think that a lower diameter will diminish the lateral projection that I do not like? Do you think that a similar or slightly smaller diameter than my current 175’s, even if the ccs are lower, will leave me with the same lateral projection “issue”?

A: When the fear from the initial implant is that is was too big, you want to make sure you don’t repeat the same problem. Given that the initial implants were only 175cc and the lowest selection is 100cc, you want to make sure you never say I didn’t go low enough. Thus choosing 100cc implants eliminates that possible outcome.

Implant base width diameter has merit but its biggest contribution in my opinion is in the initial breast augmentation when it is important to not exceed the natural width of the breast so the implants do not get too far to the sides. Once a pocket is established and the implant replacements are going down in size, that issue does not become that important anymore. For you, however, with a fear of too much projection you need to get the flattest and broadest implant base. possible…spread whatever volume there is over a wide base. But the decrease in based width diameter of a 100cc implant may also help the problem of too much lateral projection as well.

Dr. Barry Eppley

Indianapolis, Indiana

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Q: Dr. Eppley, I got breast implants one year ago an am not happy with the size. They are too big. They are only 175cc but they are just too big for me. In exchanging the implants to something smaller, I am not sure what size implant to change to In reading around online, there is much discussion about the base width diameter of the implant like its the holy grail, even though, interestingly, opinions diverge. Some say stay the same implant diameter and no larger, a bit larger, can be smaller by up to one cm, thin women should have smaller, and on and on…. so no hard-and-fast-rule it seems. But 8.2 cm (diameter of smallest available 100cc implants) to my 10.5/11cm change does seem a lot, if base width diameter is typically a consideration that you guys seem to have strong opinions on. I recognize that results are harder to pin down than one might wish, but why do you think that’s better than 130’s with a 10cm diameter, or 125 mod-plus with a 8.9cm diameter, in my case? Related to that, do you think that a lower diameter will diminish the lateral projection that I do not like? Do you think that a similar or slightly smaller diameter than my current 175’s, even if the ccs are lower, will leave me with the same lateral projection “issue”?
A: When the fear from the initial implant is that is was too big, you want to make sure you don’t repeat the same problem. Given that the initial implants were only 175cc and the lowest selection is 100cc, you want to make sure you never say I didn’t go low enough. Thus choosing 100cc implants eliminates that possible outcome.
Implant base width diameter has merit but its biggest contribution in my opinion is in the initial breast augmentation when it is important to not exceed the natural width of the breast so the implants do not get too far to the sides. Once a pocket is established and the implant replacements are going down in size, that issue does not become that important anymore. For you, however, with a fear of too much projection you need to get the flattest and broadest implant base. possible…spread whatever volume there is over a wide base. But the decrease in based width diameter of a 100cc implant may also help the problem of too much lateral projection as well.
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I recently had a breast augmentation with 175 cc implants placed under the muscle.. I went round and round with the surgeon, who had never placed implants that small. I showed him an “A” bra that I was interested in filling (I was a double A) and he assured me that that was where I would end up. No such luck. I am a very full B, and very much doubt that waiting for swelling to go down, drop and fluff, etc, will attain the very, very, very moderate look I wanted: again, an A cup. I had explained to him that I was looking to acheive an “A”, no more, to restore my former breast before the 20-lb weight loss. I am very upset to be so thin (5′ 10 and 120) and have much bigger breasts than I have ever had in my life! Would you deem me a good candidate for revision?

A: It is true that breast augmentation with implants under 200cc in volume is very rare. But yet they do make them as small as 125cc in volume. But most of such implants are used as an adjunctive component of breast lifting surgery.

Had I seen you before your desired breast augmentation procedure what I would have said is that no size of existing breast implant will make you an A cup, no matter how small you started. Even putting in a very small breast implant is going to make most women some form of a B cup even if it is a small one. Granted you are very tall and thin, but even a small breast implant will make some degree of a visible mound which is by definition a B cup.

That being said, where you do go from here…how do you revise what you have to reach your size goal? It would be extremely helpful to know whether you have saline or silicone gel implants and what projection/profile they are. For the sake of assumption, let us assume that you have silicone gel implants. There is no where to go in terms of size as the smallest silicone gel breast implant is 170cc, regardless of the manufacturer. If you have saline, then there is the possibility of downsizing particularly if the 175cc are overfilled. The smallest saline breast implant made is 125cc in the lowest or moderate projection style. By switching to this smaller saline implant, you would realize a 30% reduction in size (maybe more if they are overfilled) and perhaps some less projection if they are anything higher in projection than a low profile implant.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had a breast augmentation six months ago with silicone implants placed under the muscle through a lower fold incision. I developed a hematoma which needed to be drained by the next day. Now that all has settled down and healed, my breasts are asymmetric. They were not asymmetric prior to surgery and now they are. My doctor says that is just the way I was before surgery but I know I wasn’t. I have attached some before and after surgery pictures from different angles that I got from my doctor. Can you tell me what you think?

A:  In looking at your before and after pictures, I believe your doctor is correct. There is subtle asymmetry of the breasts before surgery with the right breast being the ‘good sister’ and the left one being the ‘bad sister’. The left one has a bit of ptosis and a slightly higher inframammary fold. That is a setup for what you are seeing. The implants may be reasonably well placed but the preoperative asymmetry has now become magnified. As you increase the size of the breasts, what was once a little difference can become much bigger. You may also have a bit of contracture on that breast from the hematoma surgery but that is speculation since I have now examined your breasts.  Given the relatively minor postoperative asymmetry, I would be hesitant to undergo a revision. You would have to go in and lower the implant to reduce the upper pole fullness. Whether that is worth the effort to undergo a breast implant revision is debatable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast augmentation six months ago and I feel that my implants are way too small. (I got Mentor 275cc silicone moderate plus gel implants placed under the muscle) I thought they were too small from the beginning but my surgeon said I would get used to them and come to feel that they were just the right size. I never have and I wear the same bra size as before surgery. When can I get new implants and what size implant should I get?

A: While some women come to accept the size of their breast implants, whether they are a bit too small or too big, they do not if the size is way off from what they expected. You have given it enough time after your initial surgery to try and accommodate to them and it is obvious that you can not. You can have replacement surgery at any time at this point. The implant size you should have based on your desires is based on information that I do not have such as breast base diameter, what your chest and body looks like and the ‘look’ of your breasts that you visually desire. But when changing out implants for a breast augmentation revision to go to a bigger size, there is one rule that I have learned. Make sure that the new implant volume is at least 30% or more from what you have now. Otherwise it will not create enough of an external visible difference. This means in your case of at least 100cc or 375cc to 400cc implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I had breast augmentation eight months ago. They were Mentor 375cc moderate profile silicone gel implants. My problem is that the implants are too widely spaced apart. My plastic surgeon told me he could fix them by removing the implants, putting in stitches into the sides of the pockets to move them closer together and then put the implants back in. I would like to have more cleavage but don’t know if this procedure is worth it. Should I have this done and how long does it take to heal?

A: While repositioning implants through suturing of the surrounding capsule (capsulorraphy) can be done to push implants in any direction, the question is how effective would it be. This is particularly relevant when trying to make implant move closer to the sternum. If these are submuscular implants, and I have to assume that they area, you must know the edges of the pectoralis muscle will block the implants from moving very close to the sternum. The reason in my opinion to undergo the procedure is to move implants inward that you feel are too far to the side…not because you think will get more cleavage. Laterally displaced implants can be reliably moved back onto a better position on the chest wall. Moving breast implants with the primary intent of creating more cleavage is less certain to be able to achieve that goal. Either way, recovering from an implant repositioning procedure is much less than the original breast augmentation surgery.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Six months ago I had breast implants with an around the nipple type of lift, I had 350cc silicone implants placed in each breast. Right after the surgery, there were a noticeable difference in the shape of my left breast. It sat lower on my chest and appeared smaller than my right breast. Can this be fixed? I have attached pictures from different angles so you can see the difference.

A: In looking at your pictures, I see a fairly good result. While I do not know what you looked like before surgery, this is an overall nice result, I do see a slight difference in the breasts with the left breast having a small amount of inferior and lateral positioning, This may or may not have to do with the location of the implant.

For the sake of discussion, let us assume that it is an implant location issue. One of the most common reasons for revisional surgery after breast augmentation surgery is implant asymmetry or malposition. This presents in many ways from an implant being too high, too low, too far to the side, to being too far to the middle. Invariably, there is always the good breast and then the bad one. (or as I call it the good sister and the bad sister)

Implants that are too low or too far to the side can be corrected using an internal suture technique decreasing the size of the pocket and moving the implant to a more symmetric position to that of the other side. Expect improvement but not perfection. It is unlikely that your breasts were perfectly symmetric from the beginning and this surgery has likely unmasked that pre-existing issue.

I would also think very carefully about revisional surgery for a minor amount of breast asymmetry. All surgery involves risks which are always greater when a synthetic implant is involved. Those risks are not necessarily less than that of the original breast augmentation/lift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a breast augmentation about three months ago. My problem is that my implants are literally touching each other. There is no gap between them. While I wanted better cleavage, this is too much. In addition, when I move my arms more than just a little bit, both implants jump to the sides which is freaky. I now know that my implants are too big and I want to go smaller. I currently have in 450cc and want to go down to 350ccs. Will I need a lift if I go down to that size? Will switching to smaller implants stop them from touching each other? I’m attaching a picture, how would you correct my problem?

A: What you have are several implant issues. First, the implant pockets nearly join over the sternum, This is known as symmastia. Downsizing your implants will not correct that problem. Correction requires the pockets to be sewn down in that area and may even require an allogeneic graft placed along the sternum to prevent recurrence. Secondly, your implants are definitely too big as they are wider than the base of your natural breasts. This is why you have both symmastia and that the implants go too far to the sides. Downsizing your breast implants by 100ccs and changing to a high profile implant will make them look more natural. Based on your pictures, you will not need a lift if you go smaller in implant size.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I had breast implants with a lift over one year ago. While they do look better than before they are very asymmetric. I had 375cc silicone gel implants and vertical breast lifts. The left breast is considerably larger than the right and the implant sits lower and more towards the side of my chest. My plastic surgeon wants to redo the lift on the left and tighten the pocket. Rather than place a bigger implant in my right breast, he wants to take more breast tissue on the left to make them more even. This doesn’t make sense to me and I think it would be better to place a bigger implant on the right to make them look more even. I think he is wrong with his plan but he won’t do it the way I think it should be done. What do you suggest I do?

A:  One of the most difficult body contouring procedures to do and get a symmetric outcome is breast reshaping. The combination procedure of lifting sagging breasts and adding volume (an augmentation-mastopexy or breast implants-lift) is challenging and the need for secondary revisions is remarkably high. (25% to 50%) When planning a revision of this operation, there can be multiple options to manipulate including more of a lift or tightening the breast skin, increasing the size of one or both implants, or even removing some breast tissue. Any or all of these may be needed and there are advantages and disadvantages to any of them. While you would prefer to exchange an implant for a bigger size, your plastic surgeon has recommended otherwise. I would make the assumption that he has a lot more experience in doing this surgery and has a good reason for making this recommendation. I would suggest you sit down with your plastic surgeon and discuss your differences. Unless the final result is perfect, and it is likely that it won’t be (better but not perfect),  you will never be happy with any outcome unless you understand and agree with the revisional plan. 

Dr. Barry Eppley

Indianapolis, Indiana