A patient about a year out from her augmentation came back for something she could feel before she could see. She trains hard. She had lost fat and gained muscle, and the upper pole of the implant had started to show through. I am publishing the exchange nearly as it happened, identifiers removed, because the three options I gave her are the same three I give everyone with this problem, and the tradeoffs are worth reading in full.
The visit
Her: So I noticed some rippling already like a few months in, probably after six months. You can’t really see, but when there’s a light hit you can see it, and you can feel the ripples.
Me: “Put your hands here and squeeze in. Okay, relax. One of the ways to make this better is to put some fat here, to make it thicker so that there’s more between the skin and the actual implant. And I can always get some from here that we can put here, or we can use something called allograft, which is a donor fat, and that I can do here in the office.”
Her: So you inject it in there?
Me: “Inject it under the skin, yeah. So that it pumps it up and it gets thicker.”
Her: Instead of like removing the whole implant and doing a different implant altogether, do you think that would change anything?
Me: “The round would be smoother.”
Her: I read about it, it’s very common with the thin patients.
Me: “It can happen, yeah.”
Her: And then also, why not under the muscle, why didn’t we consider that? Most of my friends who work out, they get it under the muscle. Maybe it could have helped me.
Me: “We could switch it under.”
Her: I really don’t wanna go underneath, but I’m just saying, would it help?
Me: “It does pad the upper pole more, but it generates a little bit of, like, the muscle wants to push it to the side. So that’s the downside of that.”
Her: Otherwise I’m happy with it, but I’m probably getting thinner, so it’s gonna look worse. It was only a year and it’s already happening.
Me: “Do you feel like you’ve lost any weight?”
Her: No, I’m training a lot, but the weight hasn’t changed.
Me: “But your fat may have gone down. More muscle, maybe a little less fat. But you never had much anyway, right? So it was always very thin. But of course, your pictures before looked better because I think it was still a little bit of swelling.”
The fat question
Me: “We can switch them to under and that will kind of squeeze down the top a little bit, but then when you exercise, you will have animation so they will move up and down.”
Her: Yeah, that’s fine.
Me: “And then you do have the option of doing the fat just to get this thicker. The allograft is very predictable. So when I use allograft, everything I inject stays. And your body will actually build a little bit on it. It’s expensive; your own fat’s a lot cheaper. But your own fat is a little bit less predictable on how much will actually take.”
Her: Over time, will the fat stay there?
Me: “It will stay, and it’ll create new fat cells.”
Her: How much are we talking?
Me: “I would wanna use at least like 25 ccs on each side, so I think we’re talking about like five, six thousand. It’s almost like the whole surgery. But with the fat graft, we can actually do it under local so there’s really no downtime, you can go back to work the next day.”
The under the muscle question
Her: And so what would you otherwise recommend doing under the muscle, just completely switching to under the muscle?
Me: “So we would be here, open, and I can use the same incision and go in, divide the muscle, bring it up. And then because your mesh is already integrated, we probably have to put a new one just to hold that muscle so that the implant doesn’t pop out to over the muscle. And that will help with the rippling from here up.”
Me: “It might give you a little bit more of a gap. But if we do get a big gap because of the muscle, we can always also put fat there to make it softer.”
Her: The recovery is what it’s about, it’s like doing it again. This recovery was fine, other than the seromas. What’s the chance of me getting seromas again?
Me: “We’re not creating any pocket here. This is just removing a little bit of skin. You won’t get a seroma there, because it’s just skin and cut. When we did your original surgery, we actually had to lift up and create a pocket.”
The dog ear and the decision
Her: Then this is easy, right? Just the dog ear.
Me: “That’s very easy. It’s not that bad. It’s just a little dog ear. I try to keep the incision as small as possible, and sometimes that happens and it bunches up.”
Me: “I think it’s best to do it all at once. And we can put that together for you. I don’t charge anything for revisions. This is the time in the OR and anesthesia, and then of course we’ll need new implants and the mesh, so that would be pretty much the cost.”
Her: I think it was within two years I can decide, right?
Me: “Yeah, we don’t have to do it today.”
Her: So maybe I’ll find a date, maybe after the holidays.
Me: “You can talk to the coordinators, they’ll put it together. They can give you some dates now, but when you’re ready, you can call them and we can set it up.”
Her: I want to stay the same size. But changing to the round, under the muscle.
Me: “Yeah. Under the muscle and round, same size. And then this will do the skin, and a little tuck there.”
My exam note that day: some rippling on the upper pole, very thin. I think she has lost some fat content, and she’s gaining muscle content. We did the test with pushing on the wall and the implants are over the muscle. On the incision she does have a little bit of excess dog ears.
Why we went over the muscle in the first place
The same week, a different patient with an old saline implant asked me about placement, and I told her what I tell everyone now: “We’ve actually moved to doing almost all of them over the muscle, because it is a big benefit. But we didn’t have the right implant before, so the reason we were putting it under the muscle is because the risk of capsular contracture was very high. But now that we have these implants, the Motiva, the capsular contracture is so low that we don’t really worry about that.” And to another: “The good thing is you have enough tissue that you’re not seeing the rippling.”
That last line is the whole subject. Rippling is a tissue problem. Thicken the tissue, change the implant, or change the plane. Those are the three answers, and the right one depends on how much of you there is over the implant.
I am a double board-certified plastic surgeon, a Mayo Clinic fellowship alum, and I teach plastic surgery as a Clinical Associate Professor at Texas Tech University Health Sciences Center.
Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at drworldwide.com.
#StayBeautiful