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Bottoming Out Patients

Reduction of Breast Implant Size with use of Allograft and Internal Bra

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This 31 year old patient from Arizona previously had XL breast augmentation surgery. She was pleased for many years and as time went on, she decided that she would like to downsize her breast implants and proceed with revisionary surgery.  Dr.Pousti believed she would benefit from downsizing of the implants as well as a breast lift and Acellular Dermal Matrix or Allograft.

implant deflation

She and Dr. Pousti discussed proceeding in stages. The first procedure would be to “deflate” the saline breast implants to allow the breast skin to slowly bounce back and redrape.   Once the saline implants are completely deflated, Dr. Pousti will have a better idea of what procedure would be necessary to achieve the patients’ goals.  In order to achieve her goals, she would need to undergo a 2 stage procedure. They would first proceed with a in-office implant deflation and then a few months down the line when her skin has “bounced-back” they would proceed with the revisionary surgery to address her breast implant size, positioning, etc.

implant removal

Below shows the patient after the saline breast implants are deflated.

revisionary breast surgery

breast lift

The patient kept in close contact with the office and a few months down the line, returned for the second stage of her procedure, which would be placement of new, smaller silicone gel breast implants, internal bra (capsulorrhaphy), anchor breast lifting as well as the use of Allograft for additional support and coverage.

breast augmentation

Markings were performed in front of a full length mirror with Dr.Pousti the morning of her surgery. They went over the procedure and her goals once more in detail and answered any last minute questions that the patient may have.

allograft (2)

Allograft was placed in each breast in hopes of additional support to reduce chances of  bottoming out and/or displacement.

internal bra

allograft

During the surgery, the patient’s previous deflated saline breast implants were removed, breast lifting was preformed and 590cc smooth round ultra high profile silicone gel implants and ADM were placed.

The anchor breast lift procedure involves a surgical incision in a ring around the breast’s areola, along with a straight incision going from the bottom of the areola to the middle of the breast crease and an extension of the incision to the left and right underneath the breast crease allowing for maximum breast lifting.

The patient is currently healing very nicely and without any complications.

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Posted in AlloDerm, Bottoming Out, Breast Implant Size Reduction, Breast Lift with Implants, Breast Revision Surgery, Downsizing Breast Implant Size


Revision Breast Surgery with Acellular Dermal Matrix

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This 44 year old female from Southern California was wanting revision breast surgery.  She was not pleased with the size, shape and positioning of her current breast implants.    Her implants were too close in the cleavage area and also bottoming out.

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She found Dr. Pousti online and was impressed by his expertise in regards to breast augmentation revision surgery and the use of Acellular Dermal Matrix.

It was determined that the patient would need breast implant exchange with new silicone gel breast implants, scar tissue removal (capsulectomy), internal bra (capsulorrhaphy) for the breast implant mal-postion, and the placement of Acellular Dermal Matrix (ADM) for additional support and coverage.

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Markings and measurements were performed the night prior to surgery. As you can see, the ADM is used medially for additional support for the internal sutures that will be placed for better placement of the breast implants on her chest wall.

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In the operating room, the patient is positioned carefully – markings and measurements are carefully re-checked prior to the start of the procedure.

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Here we show the Strattice that will be used on both breasts for the revision breast surgery.

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Below is the patient immediately after breast augmentation revision surgery with the use of AlloGraft and Internal Bra.

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The before and after photo side by side showing a nice improvement in size, shape and symmetry.

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Posted in AlloDerm, Bottoming Out, Breast Pocket Correction, Breast Revision Surgery, Capsular Contracture, Capsulorrhaphy (Internal Bra)


Breast Implant Revision with Biosynthetic Mesh and Internal Bra

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This 45 year old patient from Covina, California has been interested in revisionary breast surgery to improve the position of her breast implants.  She wanted them “more perky” with “more fullness” on top.

implant exchange

revisionary breast surgery

After discussing revisionary breast surgery with Dr. Pousti as well as her goals,  Dr. Pousti suggested the use of  biosynthetic mesh for additional support as well as the an internal bra procedure to improve her bottoming out. Bottoming Out involves inferior migration of the implants. This causes the nipple areola complex to appear too high on the breasts. Also, the distance from the areola to the inframammary fold is too great. This is corrected by “raising” the inframammary fold using internal sutures. This is performed after careful measurements are made from the areola to the “new” inframammary fold.  The internal bra or capsulorrhaphy procedure, also known as pocket correction or use of internal sutures/bra, involves closing a portion of the breast pocket to correct displacement of the implant. She agreed and they decided to proceed to the operating room soon thereafter.

XL breast augmentation

Dr.Pousti performs markings and measurements the morning of surgery as he discusses the procedure and the patients goals one last time prior to the patient being put under anesthesia.

revisionary breast surgery (2)

mesh

A biosynthetic mesh was placed in each breast to help support the over-sized saline implant that will be placed in each of the patient’s breast. This is used because the skin on her lower breast poles were so thin to start with.  TIGR Matrix surgical mesh is primarily used to reinforce soft tissue where weakness exists. The mesh technology has a high strength for the first 6 months after implantation, and is completely degraded and resorbed after approximately 3 years. TIGR Matrix surgical mesh is being used to help aid correction of breast implant complications such as bottoming-out, capsular contracture, implant repositioning, breast asymmetry, lateral displacement, unnatural implant movement, and more.

implant exchange (2)

XL breast implants

breast liftAbove, is the patient immediately after her surgery. She went from 455cc to 800cc smooth round high profile implants produced by the Mentor corporation. She also received a revisionary breats lift, an internal bra inferiorally and laterally, and the biosynthetic mesh in both breasts. She is only a few days out from surgery and is healing quite nicely.

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Posted in BioSynthetic Mesh, Bottoming Out, Breast Pocket Correction, Breast Revision Surgery, Capsulorrhaphy (Internal Bra), XL Breast Augmentation


Primary Breast Augmentation to Larger Breast Implants and then Downsizing

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This 46 year old patient from San Diego, California previously had a breast augmentation performed back in 1997. She is not happy with the size and/or shape of her breasts. She also had some “constriction” of the breasts.

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Below shows the results of her breast augmentation surgery early on in recovery.

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Over a period of 6 years after her initial breast augmentation procedure she started to develop  bottoming out of the left breast as well as rippling in the cleavage area.

revisionary breast surgery

Bottoming out involves inferior migration of the implants. This causes the nipple areola complex to appear too high on the breasts. Also, the distance from the areola to the inframammary fold is too great. This is because support of the implant by the skin alone is not always enough to prevent downward migration of the implants. Also, over-dissection of implant pockets at the time of surgery may cause immediate bottoming out. This is corrected by “raising” the inframammary fold using internal sutures. This is done after careful measurements are made from the areola to the “new” inframammary fold. Because of the bottoming out that was happening on her left side she decided to undergo revisionary breast surgery for the internal bra technique as well as to increase her breast implant size and change from saline breast implants to silicone gel breast implants.

revisionary breast surgery

Above photo shows the patient 1-2 weeks post op revisionary breast surgery after capsulorrhaphy of the left breast. Implant size was changed from 330cc saline implants to 550cc smooth round moderate silicone gel implants produced by the Mentor corporation. She was very happy with her results. Below is a photo of the patient taken 7 years post op from the initial revisionary breast procedure.

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This is the patient 7 1/2 years post op from her last revisionary surgery. She was very pleased with her results, however, 3 years after having a child she was ready for a change. She came in to see Dr.Pousti to discuss revisionary breast surgery once more but this time she wanted to downsize her implants. She wanted to go smaller than the size she has currently. After discussing it with Dr.Pousti he knew that this was possible and they both were ready to proceed to the operating room soon thereafter.

implant exchangeWhen discussing the “downsizing” procedure, the patient did not want breast lifting and so she asked Dr. Pousti to make her as small as possible without having to do a breast lift procedure.  She and Dr. Pousti also discussed performing the internal bra bilaterally to make sure the breast implant pockets were adjusted properly.

downsizing breast implants

implant exchange

implant exchange

Above, is the patient 2 weeks after downsizing her implants. She went from 550cc silicone gel implants to 375cc smooth round high profile silicone gel implants produced by the Mentor corporation. She is very pleased with her results and is healing very well and without any complications.

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Posted in Bottoming Out, Breast Implant Size Reduction, Breast Revision Surgery, Capsulorrhaphy (Internal Bra), Downsizing Breast Implant Size


Bottoming out

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This 46 year old patient from San Diego, California previously had a breast augmentation and now was experiencing bottoming out with her left breast.
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Bottoming Out involves inferior migration of the implants. It is the loss of internal implant support where implant placement with partial, or no, muscle coverage, allows slow downward migration of the implants. This is because support of the implant by the skin alone is not always enough to prevent downward migration of the implants. This is corrected by “raising” the inframammary fold using internal sutures. When she came in for a follow up with Dr.Pousti she brought up her issue and after examining her he deemed her a good candidate for revisionary breast surgery. To fix the bottoming out issue He would exchange the implants and revise the left breast pocket. They decided to proceed with surgery soon thereafter.
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She is currently 7 years post revisionary surgery and is very pleased with her results.

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Posted in Bottoming Out, Breast Pocket Correction, Breast Revision Surgery


Implant Displacement Correction with Internal Bra

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This 34 year old patient from Spring Valley, California previously had a breast augmentation performed by another surgeon. She was unhappy with the appearance of her breasts and was ready for a change. She suffered from lateral displacement which occurs when breast implants shift towards the armpit.

internal bra

At her consultation  and examination by Dr.Pousti, it was determined that she would benefit from revisionary breast surgery and also capsulorrhapy or an internal bra to correct the lateral breast implant mal-position (implants moving toward her armpits).

implant exchange

Below, Dr.Pousti performs markings on the patient the morning of surgery. They also go over any last minute-questions, concerns, or goals the pateitn may have before they proceed to the operating room.

internal bra (2)

revisionary breast surgeryThe previous implants were removed and the new implants will be chosen by Dr.Pousti in the operating room according to what the patient and him had discussed. He will insert the new implant with the Keller Funnel. The cone-shaped design of the Keller Funnel offers a no-touch delivery technique. First, the tip of the device is placed through the incision in the breast. Once the device is in place, the surgeon quickly yet gently propels the implant into place with minimal force. The Keller Funnel is made of nylon with a special inner coating that creates a slick surface for delivery of the implant. The implant never comes into contact with the skin.

revisionary breast surgery (2)

implant exchange (2)

implant exchange (3)

Above, is the patient directly after her revisionary breast augmentation surgery.

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Posted in Bottoming Out, Breast Pocket Correction, Breast Revision Surgery, Capsulorrhaphy (Internal Bra)


Revisionary Breast Augmentation Surgery with Internal Bra

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This 23 year old patient from Philadelphia, Pennsylvania previously had a breast augmentation a few years ago from another plastic surgeon and as years passed she was not happy with her results. She decided to wanted to undergo revisionary breast surgery and started to research plastic surgeons around the world. She was looking for a surgeon with experience with breast augmentation revision surgery.

implant exchange (2)

revisionary breast surgery (2)After communicating via email, Dr.Pousti recommended that it would be beneficial to proceed with the internal bra procedure (capsulorrhaphy), also known as pocket correction or use of internal sutures which involves closing a portion of the breast pocket to correct displacement of the implant. The internal bra along with exchanging her implants would help ultimately give the patient the look she is trying to achieve.

breast implants

internal bra

silicone implantsThe patient originally started out with 380cc implants. Dr.Pousti removed the previous implants and inserted “sizers” first. The sizers help identify what size implant he will ultimately be inserting into the patients breast.

revisionary breast surgery (3)

revisionary breast surgeryThe patient currently has 565cc high profile silicone gel implants from the Sientra company. She is currently 1 week and 2 days out from revisionary breast surgery and is doing very well. She will keep Dr.Pousti updated through emails and phone calls.

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Posted in Bottoming Out, Breast Pocket Correction, Breast Revision Surgery, Capsulorrhaphy (Internal Bra)


Revisionary breast surgery and implant removal (internal sutures)

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This 37 year old mother from Las Vegas, Nevada has been thinking about breast implant size reduction surgery for a number of years. She has also considered liposuction for a number of years as well.  She met with Dr. Pousti and was very pleased with her consult that she booked her surgery soon thereafter. She is currently 4 weeks post revisionary breast surgery and is very pleased with her results.

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After careful consideration of the risks and benefits of a breast implant removal or breast implant size reduction, the patient scheduled for surgery.

Before the surgery (with markings) and directly after the breast reduction

Before the surgery (with markings) and directly after revisionary breast surgery.

Before the surgery (with markings) and directly after with 330cc silicone gel implants in both breasts

Before the surgery (with markings) and directly after with 330cc silicone gel implants in both breasts. She has 330cc silicone gel implants in both breasts.

Before the surgery and 4 weeks post symmastia repairThis is the patient at her pre-op appointment before her surgery and, on the right is her 4 weeks post revisionary breast surgery.

Right side view before the surgery and 4 weeks after surgeryRight side view of the patient before surgery and 4 weeks after surgery.

DSC05368Left side view of the patient before surgery and 4 weeks post revisionary breast surgery.

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Posted in Bottoming Out, Breast Revision Surgery, Capsulorrhaphy (Internal Bra), Implant Removal


Revisionary Surgery to Improve Bottoming Out

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This 28 year old female patient from Draper, Utah had been interested in revisionary breast surgery for a few years. Her extensive online research led her to double certified plastic surgeon, Dr. Pousti. She contacted Dr. Pousti via email who told her she was a good candidate for revisionary breast surgery with capsulorrhaphy or internal sutures. She was experiencing bottoming out and was not pleased with the placement of the implants.

before surgeryShe was very impressed by his knowledge and expertise through email that she scheduled her in-person consultation. During her consultation the patient knew Dr. Pousti was going to be her surgeon. Surgery was scheduled soon thereafter.

side views before surgeryDr. Pousti discussed the use of 2 layers of internal sutures placed in the breast implant capsule to allow for better placement of the implants on the chest wall.

dr performing markingsMarkings and measurements were performed and the procedure was discussed in detail with the patient the night prior to surgery and again the morning of surgery.

pt directly before surgeryThe arrows indicate where the patient wants “more fullness” and the blue area on the lower pole of the breasts are where the internal sutures will be placed.

during surgery with implants removedPatient with implants extracted from the breasts.

front view directly after surgeryPatient directly after surgery with new implants inserted. She has 655cc silicone gel implants in both breasts.

pt directly before and directly after surgeryHere is the comparison of the patient directly before surgery and directly after surgery.

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Here is the patient sending updated photos to Dr. Pousti 2 months post revisionary breast surgery. She is doing very well and is pleased with her results.

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Side views of patient 2 months after surgery.

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Posted in Bottoming Out, Breast Pocket Correction, Breast Revision Surgery, Capsulorrhaphy (Internal Bra)


Bottoming Out Correction

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This patient was 4 years post bilateral breast augmentation and was experiencing implant displacement (bottoming out). Bottoming Out involves inferior migration of the implants. This causes the nipple areola complex to appear too high on the breasts. Also, the distance from the areola to the inframammary fold is too great. It is the loss of internal implant support where implant placement with partial, or no, muscle coverage, allows slow downward migration of the implants. This is because support of the implant by the skin alone is not always enough to prevent downward migration of the implants. Also, over-dissection of implant pockets at the time of surgery may cause immediate bottoming out. This is corrected by “raising” the inframammary fold using internal sutures. This is done after careful measurements are made from the areola to the “new” inframammary fold. The patient desired to undergo breast revision surgery in order to correct her implant malposition.before implant exchange and breast pocket correction (capsulorrhaphy)

Through the internet, she came across double board certified surgeon, Dr. Pousti. She proceeded with an in-office consultation to discuss her option. Dr. Pousti recommended replacing her saline implants with cohesive silicone gel breast implants. In order to achieve an improved outcome, Dr. Pousti determined that capsulorrhaphy would be necessary. The capsulorrhaphy procedure, also known as pocket correction or use of internal sutures/bra, involves closing a portion of the breast pocket to correct displacement of the implant.

side view before implant exchange and breast pocket correction (capsulorrhaphy)

The markings and measurements are performed prior to surgery. Dr. Pousti and the patient discuss the procedure and the patient’s goals one last time before proceeding.

markings for implant exchange and breast pocket correction (capsulorrhaphy)

An intra-operative sizer is used on the right breast after capsulorrhaphy is performed to help Dr. Pousti determine what size implant will be used in order to achieve the patients goals.

intra-operative sizer during implant exchange and breast pocket correction (capsulorrhaphy)

Both implants are removed so that the breasts could be re-augmented.

implant exchange and breast pocket correction (capsulorrhaphy)

Below, the patient is shown before and after surgery. She has 565cc (right) and 545cc (left) high profile Sientra silicone gel breast implants.

before and after implant exchange and breast pocket correction (capsulorrhaphy)

side view after implant exchange and breast pocket correction (capsulorrhaphy)

The steri-strip tapes and dressing will help add support and encourage the best possible healing.

after implant exchange and breast pocket correction (capsulorrhaphy)

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Posted in Bottoming Out, Breast Pocket Correction, Breast Revision Surgery, Capsulorrhaphy (Internal Bra)



Pousti Plastic Surgery Center
Pousti Plastic Surgery of San Diego
8851 Center Drive, Suite 300
La Mesa, California 91942
Phone: (619) 466-8851 or Email
 
Dr. Tom Pousti is a San Diego and La Jolla Plastic Surgery specialist. He has provided plastic surgery treatments to many San Diego and La Jolla facelift, tummy tuck, liposuction, breast augmentation, and rhinoplasty patients. His office is located in San Diego, and also serves the La Jolla, Riverside, Inland Empire and Temecula areas. Disclaimer


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