Posted on

The Five Words You Learn After a Bad Boob Job, and What I Actually Do About Each

Black and white photograph of a woman in a silk slip dress seated with her back to the camera on the edge of a hotel bed, a lamp lit beside her, no face. Illustrative image, not a patient. Commentary by Frank Agullo, MD, FACS.

Nobody studies bottoming out, double bubble, lateral slide, waterfall, or capsule before breast augmentation. They study them afterward, at 2am, on a forum, with a photo of their own chest open in a separate tab.

And by the time those patients get to me on RealSelf, they’ve already picked one of the words for themselves. Sometimes it’s the right one.

Five RealSelf Q&As from this year, paraphrased and de-identified. My answers, lightly edited for the page.

“Have my implants bottomed out again? My nipples look high now.”

Answered on RealSelf, Jun 2026.

Bottoming out and high nipples are the same thing. When the implant bottoms out and moves below the breast fold it takes the volume with it and this will make your nipple/areola complex appear higher than expected. I can see this in your side picture as well with most of the volume sitting low and the nipple sitting high. Going from 200 and 250 cc implants to 320 and 350 cc implants likely added more weight to an already weakened lower pole that bottomed out in the past and this allowed the breast fold to stretch down again.

In order to correct this issue it would require going back in and performing a breast fold plication (capsulorrhaphy) to tighten up the pocket and move the implant back up to the appropriate position. I would perform this with mesh support (GalaFlex or dermal matrix) considering your breast pocket/tissue has already bottomed out in the past. I would also discuss maintaining your implant size or potentially going slightly smaller to take as much stress off of the breast fold plication as possible. A lift revision, without moving the nipple is likely necessary.

“Six months after augmentation with a small lift, what has gone wrong?”

Answered on RealSelf, May 2026.

The deformity you have developed is called a “waterfall” deformity. The implant position looks good. It’s your breast tissue that has fallen off of the implant, which you are feeling when you lay on your side. The small areola lift that you had will not adequately address your breast tissue falling off of the implant. The suture spitting is a wound healing issue that is separate from your deformity.

Revision surgery could help improve your waterfall deformity. Based on the degree of your deformity and amount of extra skin a Benelli/donut lift revision (larger than what you have already had) or more likely a traditional vertical/anchor lift revision may be performed to help move your breast tissue back up on top of your implant. I will often use a mesh product (GalaFlex Lite) to place over the top of the implant to try and maintain the position of the implant. You are healed enough (6 months) to consider revision surgery.

“My implants have slid out to the sides. Is that my chest or the surgery?”

Answered on RealSelf, May 2026.

I realize you are concerned about lateral slide, however it appears that you actually have 2 different issues going on. First you have a wider chest wall. The second issue is most likely an overly dissected implant pocket laterally by your original surgeon.

With wider chest walls there is more surface area for the implant to slide onto. I’m actually reassured with your photos that you have good cleavage formation when standing which suggests to me that your anatomy is likely not the issue here. Instead I’m concerned that you have some lateral slide of the implant where the implant is migrating too far laterally in the implant pocket causing a larger gap between the breasts. In this scenario I would consider revision surgery with a capsulorraphy using permanent sutures to plicate the implant pocket medially. This would likely also require a mesh material (P4HB or GalaFlex) to help support the capsule contract medially over time. If the implant profile/base width is too wide this may also need to be addressed at time of revision by exchanging for a smaller implant. Subfascial placement may also help with patients that have wider chest walls, however it’s likely in your scenario that addressing the implant pocket would be the main procedure needed to improve this.

It’s good to hear you have no pain at 2 years post-op. And aesthetically this issue can be improved.

“I want more upper fullness. Can I avoid a lift?”

Answered on RealSelf, Jun 2026.

It’s good that 2 out of 3 of your doctors in person do not think you need a lift as I would side with their comments over mine since mine would be based off of educated guessing through photos. I do agree that your upper poles are flat, this can happen with saline implants placed above the muscle that have been in for 14 years. I do think that your nipple areola complex is positioned a little low and there is breast tissue hanging below the nipple areola complex. Whether you need a lift or not will really depend on how high your nipple sits in relationship to your breast fold. Yours appears to be right on the fold. If it’s lower than this then getting larger implants would just end up giving you more ptotic breasts with a larger implant that the breast tissue slides off of and more tissue below the nipple, ie “waterfall” effect. I think you could do well with a small circumareolar lift.

As far as getting fullness I think a cohesive gel implant with a higher profile would help here more than deciding if its above or below the muscle. I understand you do not want it below the muscle as you are active and do not like the way it moves when you contract your pec. You can get fullness above the muscle you just will sacrifice a little coverage and accept a little more palpable/visible implant edge.

“My implants look like disks on my chest. What makes them look natural?”

Answered on RealSelf, May 2026.

From your photos yes you do look a bit like there are disks sitting on your chest. This can happen with subfascial placement since the implant is placed above the pec muscle, it can’t slip underneath like a submuscular implant. Combined with your previous lollipop incision and thinner tissue in the upper breast I can see how this may occur. I don’t think this will change over time.

If I was operating I would perform a:

  • Medial capsulorrhaphy, this is basically using permanent sutures to narrow the inside aspect of the implant pocket so the implants can’t migrate medially

  • Lateral implant pocket release, this would allow the implant to fall more laterally on the chest wall

  • I would recommend a smaller implant size with a width smaller than the ergo mini 220 and a lower profile implant so that you don’t flatten out as much when you lay down

  • Fat grafting, using lipofilling to the upper pole to help hide the implant contour especially superior medially. This can help camouflage the implant in patients with thinner tissues.

It would all be done in one surgery. You should discuss all of this with your surgeon.

Depending on if your skin envelope continues to thin out you should discuss possibly converting to a dual plane as well. Don’t pass on the lipofilling. It’s not a lot of fat, but it can make a world of difference.

The rule

  1. The implant pocket is key, support the pocket with mesh if necessary. Don’t believe tissue that has been expanded can be trusted to not do so again.
  2. The implant is the last thing I change, not the first!
  3. A lift is a lift… it’s just not called a “fold revision.”

Ten of these, with the full table, are on my surgical site.

Why choose Dr. Agullo

I am certified by the American Board of Plastic Surgery and the American Board of Surgery, completed my plastic surgery fellowship at the Mayo Clinic, and serve as Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly has listed me as a Top Doctor every year from 2014 through 2026. Breast revision is a large part of my practice, and most of it is other people’s augmentations.

Ready to talk?

Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com/appointments. More of my answers are on RealSelf. #StayBeautiful

Find me at @RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.

Posted on

If You Can Feel the Mesh, Your Tissue Is Thin: A Surgeon on the Internal Bra

Black and white close-up photograph of a sheet of fine surgical mesh held up against hard side light so the weave shows, dark background, gloved fingertips at the edge of the frame, no face. Illustrative image. Commentary by Frank Agullo, MD, FACS.

A sheet of mesh the size of your palm. Two years, then gone, collagen left behind. I put one in nearly every breast operation I do.

Every Lift, Every Reduction, Every Augmentation

“I actually recommend internal mesh support on all patients, on breast lifts, breast reductions, and breast augmentations.”

“In a breast lift and a breast reduction, it actually helps reshape the breast tissue and support it, just like a push-up bra, to gain more upper pole fullness and avoid bottoming out and lateral displacement.”

“Of course, this is a recommendation, and some patients decline using the mesh, with the knowledge that they will not have that added support.”

Two Years

“The mesh supports the tissues for a period of up to two years. As it dissolves, it leaves behind collagen deposits, so the support remains there even well after the mesh has gone.”

“I use two main types of mesh. GalaFLEX, including GalaFLEX LITE, which is lighter, and DuraSorb mesh. The choice depends on each patient and what we want to achieve.”

The Worry

“We have not had a single case of infected mesh when we have used DuraSorb or GalaFLEX, and we have never had to remove the mesh.”

My practice. Not a study.

“We have been using internal mesh support for breast reconstruction for more than 20 years, and these techniques have been incorporated into aesthetic surgery. There are always risks associated with using any implanted material. In my experience with GalaFLEX and DuraSorb, I have seen significantly fewer complications, if any, compared to other mesh systems and dermal grafts. A lot of the symptoms alleged to have resulted from the use of mesh can actually occur when we don’t use a mesh at all.”

The Fact Nobody Tells You

“There have been cases where the mesh is palpable, and we have decreased this risk by changing to GalaFLEX LITE, which is thinner and less palpable, and to DuraSorb. The fact that the mesh can sometimes be palpated is a sign that the patient has very thin tissues, through which the mesh can be felt. If we had not used a mesh in these cases, we would probably be able to palpate the implant or visually see rippling. In these cases, the mesh is actually helping to thicken the skin and tissue envelope, and as the mesh dissolves over time, that palpability disappears.”

Feel the mesh, or feel the implant. That is the choice thin tissue gives you. Rippling is the version without the mesh.

“It is important to also realize that there are risks involved with not using a mesh. These risks include rippling, implant palpability, and implant displacement.”

She asks The answer
Do I need it? I recommend it on every lift, reduction and augmentation; declining is her call
How long is it in there? Up to two years, then collagen in its place
What if I can feel it? Thin tissue; without the mesh she would feel the implant
Does it change recovery? No, and not the drain either

Contracture

“In all actuality, there has been increasing evidence that the use of GalaFLEX and DuraSorb can decrease the risk of capsular contracture or capsular contracture recurrence. In many cases of recurrent capsular contracture, we are actually recommending a complete wrap of the implant with GalaFLEX or DuraSorb mesh to decrease the risk of recurrence.”

More on that in the capsular contracture revision read.

Recovery

“When we use a mesh, it does not change recovery time, it does not change whether we use a drain or not, and it does not affect how long the drain stays if we do decide to use one.”

The operation where the mesh earns its keep is the auto augmentation lift. The surgical read with the cost ranges is on agulloplasticsurgery.com; the patient version is on the Southwest Plastic Surgery post.

Why Choose Dr. Agullo

Double board-certified, by the American Board of Plastic Surgery and the American Board of Surgery. Mayo Clinic plastic surgery fellowship. Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly Top Doctor for 13 consecutive years.

Ready to Talk?

Ask to hold the mesh. Then decide. (915) 590-7900, text 1-866-814-0038, or book at agulloplasticsurgery.com/appointments. #StayBeautiful

@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.

Posted on

A Lift Alone Can Make You Smaller. Somebody Should Say That First.

Black and white torn-paper collage of two cut-out portraits of poised women with engraved magnolia beside a large numeral reading 4th.

Breast lift was the fourth most common cosmetic operation in the country last year. It is also the one where expectations most often go wrong, and usually in two specific ways.

First: a lift on its own does not add size

“If a patient just wants to have a breast lift, then they have to understand that they may be the same size or slightly smaller, maybe half a cup size to a cup size, because we are removing that excess skin. The breast will be perkier, but it’ll also be tighter, and it may appear smaller.”

If you want to be larger, that is a different operation.

“Of course, if they want to be larger, we will need an implant or a fat transfer to the breast. The biggest difference here is that an implant is very predictable, and fat transfer to the breast is going to be a slight change, very natural, and a little bit unpredictable in terms of how much of the fat actually stays, but we can usually count on about a cup size increase.”

Second: the upper pole

“A lot of patients having a breast lift with implants are expecting a lot of upper fullness and a very high implant placement, which is just not possible at the same time as a breast lift. A breast lift will always give a perkier look, more upper fullness, and cleavage, but it’s going to have usually a natural slope on top.”

A natural slope is the result, not a failure of the result.

The incision people are afraid of

“I think a lot of patients are afraid of this surgery because they feel like they’re going to need the full anchor type incision. By offering the circumareolar, or donut, lift for patients whose nipple and areola are above the inframammary fold, this can be a game changer.”

That is an anatomy question, settled at the consultation, not a preference.

Why I put mesh in

“Regardless of the combination of procedures we perform, I do recommend using an internal bra with mesh support, with GalaFLEX or DuraSorb, to give us that support of the breast weight, so that we’re not just relying on skin, which has lost all its elastin and is not reliable long term.”

Skin that stretched once will stretch again. It is not a load-bearing structure.

What the price actually depends on

“Using an implant and/or internal bra support mesh will increase the cost. If a procedure is going to take longer, that can increase the surgical and operative time cost. And any other procedures that we add on, like sometimes liposuction of the lateral chest with Renuvion J-Plasma, or the axilla and upper back, can increase the cost as well.”

On size

“I think the bulk of patients still use the three hundred to four hundred CC implants, which give them one to two and a half cup sizes depending on their starting point.”

Some want far more, and I offer the Mentor MemoryGel Enhance line, which runs up to 1,445cc. Others want less, under 300cc, sometimes with Motiva Preserve for a faster recovery.

“So really, I have a wide range of patients, and I like to help them achieve what they desire in a safe framework, and have a good conversation about how we can get them there.”

Consultations at Southwest Plastic Surgery in El Paso.

Call (915) 590-7900 or text 1-866-814-0038.

#StayBeautiful

Source: Commentary from Dr. Agullo’s 2026-09-07 dictation. Mentor MemoryGel Enhance ceiling of 1,445cc confirmed by Dr. Agullo 2026-09-07.