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Bottoming Out Patients

Revision Breast Augmentation for Bottoming Out

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This 33 year old patient from Carlsbad, California (Northern San Diego County) previously had breast surgery but was now experiencing implant displacement of her right breast implant and needed revision breast surgery.  She wanted to fix the “bottoming out” and read that the internal bra (capsulorrhaphy) procedure was the best way to correct this.breast procedure

After in person evaluation and discussion of her goals, it was determined that Dr. Pousti would exchange the patient’s breast implants for larger breast implants and also perform the internal capsule work (capsulorrhaphy) on the right breast to improve placement of the breast implant on her chest wall.

capsulorraphy

saline implants

Above shows the markings and measurements of the patient with the “red arrows” indicating where the patient would like “more fullness”.

overfilled saline implants

Above shows the patient after removal of breast implants.

implant exachange

overfill

saline

Above shows the results after removal of 800cc breast implants and replacement with overfilled saline breast implants –1320cc on right side and 1200cc on left side.

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Posted in Bottoming Out, Breast Pocket Correction, Breast Revision Surgery, Capsulorrhaphy (Internal Bra), Overfilled Saline Breast Implants, XL Breast Augmentation


Revision Breast Surgery – Bottoming Out and Lateral Breast Implant Displacement

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This 27 year old from Canada previously had breast augmentation surgery (performed elsewhere) and ha been thinking about revision breast surgery for 5+ years. She was not happy with the “bottoming out” and “lateral displacement” (implants falling out toward her armpits).

breast procedure

She researched for the best plastic surgeon to perform her internal bra procedure as well as to increase her breast implant size.  She had read that Dr. Pousti performs capsulorrhaphy using 2 layers of sutures within the capsule for better placement of the breast implants on the patient’s chest wall.  She thought his technique provided with consistently nice results and so she proceeded to book surgery after her consultation.

capsulorraphy

Dr. Pousti performs markings and measurements prior to surgery and these act as a roadmap during the surgical procedure.

saline

The red “arrows” indicate where the patient is wanting more “fullness”

markings

The capsulorrhaphy is performed on the outer part (lateral aspect) of the breast implant pocket to bring the breast implants more medially (toward the cleavage) as well as under the breast to correct the bottoming out.

markings in office

impalnts

 

Markings and measurements are checked again prior to entering the operating room.

implant displacment

Below shows the patient in the operating room with the temporary sizer in place.  Dr. Pousti uses the temporary sizers to be able to evaluate size, shape and symmetry prior to placement of the breast implants.

revision

Due to the patients’ breast asymmetry, different size breast implants were placed.  Her 450 cc breast implants were replaced with larger high profile saline breast implants- 880cc on the right and 840cc on the left.

breast surgery

Below shows the patient with the steri strips and bolster dressing that will provide support to the area where the internal capsule work is performed.  The bolster dressing is kept in place for the first 4-6 weeks after surgery.

right after surgery

 

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


Internal Bra Technique

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This 33 year old patient from Texas was interested in revision breast surgery with larger breast implants.  She had been thinking about this surgery for over  7 years.  She was also in the medical field and so she researched for the best plastic surgeon to perform her breast augmentation revision surgery.

breast procedure
This patient was interested in the internal bra technique to address the positioning of the breast implants on her chest wall.  She wanted more fullness on top as well.
revision

bilateral breast re-augmentation silicone gel implants
The patient (below) showing the difference with size and fullness of the breasts after her breast surgery.  She is pleased with the early results of her surgery.
bilateral breast capsulorraphy

revision bilateral breast augmentation
Above: showing the patient “before” and immediately after revision breast augmentation with 700cc on each breast ultra high profile

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


Revision Breast Surgery with Use of Strattice and Internal Bra

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This 42 year old from Alpine, California had been interested in breast augmentation revision for quite some time.  Her previous breast surgery (performed by a different surgeon) was many years ago and now the patient was not happy with the size, shape or placement of the breast implants.  She was researching for the best breast augmentation revision surgeon and found Dr. Pousti.

breast augmentation revision

After examination, it was determined that the patient was a good candidate for revision breast surgery that would include revision mastopexy as well as the use of acellular dermal matrix and internal bra.

bilateral breast revision surgery

Markings and measurements were performed prior to surgery and planned procedure was discussed in detail with the patient one more time. Questions were answered and potential risks and complications were reviewed again.

bilateral breast capsulorraphy

 

To achieve the “round / perky” look the patient was wanting, Dr. Pousti discussed capsulorrhaphy and the use of Strattice for additional support.  The capsulorrhaphy procedure involves the use of sutures within the capsule that has formed around the breast implant to adjust the breast implant pocket for better placement on the patient’s chest wall.

bilateral beast augmentation

Above shows the Strattice being placed and below photos show one side completed compared to other side that has not been revised yet.

mastopexy

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bilateral breast re-augmentation silicone gel implants

Above, you will see the patient’s photos before and immediately after revision breast surgery with the use of 750cc ultra high profile breast implants.

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


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.
bottoming out
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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.
revisionary breast surgery
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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)



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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