BREAST IMPLANT SIZING 101
Comments
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Stix,
Yes, bottoming out is when implants move downward on chest wall, but it is when they pass "below" the IMF, not "over" it. Your crease will move downward with the implant. Ptosis is when you have a lot of overhang over the IMF. Your implants will look saggy, but your IMF remains intact.
This is for example, ptosis (the black line marks the IMF):
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And this is ptosis with an implant (augmented breasts):
This is bottoming out (I chose a pic where it was only happening on one side to show the difference between what was her original IMF on the one side, and how bottoming out has destroyed her original IMF on the bottomed out side (obviously this is a woman with augmented breasts, but the condition is still the same). As in the definition you cited, the breast implant here has extended below the lower breast fold and is moving down her chest wall:
Women with breast tissue and implants often may also see a "double bubble" effect, without breast tissue you won't see this.
So if the implant is too heavy for the skin you have a lot of overhang of the implant OVER your IMF (and your IMF remains intact) then you have significant ptosis. If your implant is moving down below the IMF and your IMF is moving downward on your chest wall then you have bottoming out. Because you say your IMF are still even (and it sounds like where they were to begin with) it sounds more like the issue may be ptosis (and lateral migration) caused by very lax tissues.
If it is ptosis, and your IMF remains intact, you will likely need a lift to remove excess skin. And lateral pocket repair if you are having lateral migration. I am not sure what the technique would be for a lift in a recon patient but I have heard of it being done.
If it is bottoming out, you will need a re-repair of the IMF (and lateral repair).
I really don't know how many cc's they would reduce if at all, it varies from person to person, and as I said before is not always necessary, and still no guarantee you would not have a recurrence of whatever issue it is again. As a recon patient, the considerations for size are different than with an augmentation patient and very particular to your body.
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Stix, I used the words bottoming out after seeing photos on the internet. My PS says that's something that happens with breast augmentation and just says my implants have dropped below the IMF. My surgery incisions have all been in the IMF so it's easy to see by the scars that the IMF is about an inch above the bottom of the implants now. This is not the first time either. I'll be having another surgery this week and he will be putting in Alloderm to see if that will help keep things in place. My skin is thin. Six months ago during another surgery, he put in another row of sutures on the left side but the "fix" didn't work. I never have had any ptosis. Clothes that have a high waist don't stay put and instead ride up and over the implants. I asked if the implants were too big but he says no, they are good for my frame and something a little smaller won't make a difference.
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I'm in the overfill stage of my tissue expansion after a DMX. I think that I want to go with 450 or 475 cc implants, but I'm looking for advice. I am 5'5, weigh about 120, and have a 32" bra band size. I'd like to be a full B or small C cup. Any advice on type/details of implant would be much appreciated. I will have a detailed conversation with my PS about this as well, but I'd like advice from someone who has been through it as well. Thanks!!
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mevanatta: I think there is a specific use for the Sientra round implants, and perhaps they just were not the right choice for your frame. I would rather see you with Allergan or Mentor high profile smooth silicone rounds, 750 ccs or 800 ccs. But you are not that far away from 750 ccs, and so I think you should be seeing more shape than you are seeing currently. So before you start thinking about a revision, there are some things to try first.
I personally think that wearing a compression bra for three weeks is overkill and archaic. You should be in a bra which encapsulates the implants, rather than compresses them. What is the point? Look for a Wacoal Awareness bra. You can find them a Dillards, Macy's and Nordstroms and also online. Just buy one bra. Check with your insurance, because they may pay for it. Wear it for two months and if you are still unhappy with the size, you might want to consider an exchange to larger implants.
If you want to send me photos, I might have a better idea of what is going on. You can PM me photos or obtain my email address.
Deborah
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pinkgloves:
Please read from the thread header:
3. IMPLANT SIZING INFORMATION:
If you are interested in discussing implant sizes, make sure you compile and provide us with the following information: Forget the part about the height/weight/ribcage...I have that...I need your TE info.
Height, weight, ribcage measurement [measuring the circumference of your ribcage under your tissue expander(s) or under your bra line]. Also, if you have TEs [tissue expanders] - we need to know about them. The style - Mentor or Allergan most likely - and whether they are short height, moderate height, full height if Mentor and style number if Allergan. We also need the recommended fill volume of the TEs - the number of cc's. (NOTE: If you have PMT Corporation tissue expanders or any other unlisted manufacturer, please see if your PS will provide you with the dimensions of such devices.]0 -
I have Natrelle Style 133V series tissue expanders - specifically 133FX-12, 450cc on both the left and right side.
My ribcage measures about 28" - I gave you a bra band size of 32 before, but that is the bra size not the measurement under the expanders.
Thanks Whippetmom!
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pinkgloves: Yes, Allergan Style 20, 450 ccs or 475 ccs should be ideal! Don't overfill too much!
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whippetmom: Had tons of texting with PS on Fri., using the Allergan catalog link you provided. Allergan is her TE and implant brand of choice. She said she will likely use 133VMX and 410MX, 13cm width. I am seeing her tomorrow, day before surgery, for one last check and sizing, planning, etc. Before Feb., I was 38 DD - long and wide, symmetrical. Hoping for a C-D result when all is done.
mommyathome: In my first post on this thread, I included the fact that cancer had been found in the remaining breast (left mx was in Feb.). Not the happiest news. It is early, stage 1, grade 1, and looked exactly like what I saw on the screen at my Jan. biopsy. Hoping for the same outcome - no extra nodes, no rads, no chemo. Won't know all that til Oct. 14. Left breast was undergoing Brava AFT, with a fat transfer failure in July. With this new development, I have decided to be done with everything. I will get TEs on both sides Wed. and implants when ready.
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divecat- plastic surgeons have their opinion about bottoming out. We could go to two different websites and read two different things. Its all in the eye of the beholder. Sandra 4611 keep us posted! Good Luck!0 -
Some interesting reading about bottoming out: I found this online: http://www.realself.com/question/breast-implants-side-effects-bottom-out0 -
Fair enough Stix, I think I will just have to agree to disagree on the terminology. Bottoming out is really an implant displacement issue (called inferior displacement) and I have never seen a surgeon call excessive sagging over the IMF in the absence of actual inferior displacement "bottoming out". That is not to say none of them have, it is just not what I have ever seen in any of my research on implant migration.
Here is a journal article from the Journal of American Plastic Surgeons on bottoming out repair that describes bottoming out as:
"Bottoming out is a complication of breast implant surgery that consists of the descent of the inframammary fold with inferior displacement of the implant, causing breast asymmetry. Release of the lower pole for adjustment of the inframammary fold1 can result in insufficient capsular support, and the downward pectoral muscle action can contribute to push and keep the implant in a lower position."
http://journals.lww.com/plasreconsurg/fulltext/200...
That definition has always been my understanding of bottoming out. Once again, not to say that others may not use the terminology differently, but it is important whatever you have going on you get the correct repair for that condition.
As Sandra pointed out, her IMF scar was "moving up" her breast, which as one of the PS's on your link says can be a tipoff of bottoming out as the implant is displacing down the chest wall - past the original IMF or "below the breast fold" as another PS on the stated. Of course not all of us have such visible signals like IMF incisions! But if you do, and the incision has moved UP your breast, then you may indeed have inferior displacement.
Whatever is going on for you, I hope your PS can correct the issue for you. I still think it would be a good idea, if you haven't, to contact Deborah and maybe provide her a photo of what is going on as I am quite positive she will be able to advise what is going on, whatever it is!
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Thanks divecat appreciate your thoughts. All too familiar with opinions and terminology and how it can be used loosely. ... i too am in the medical field. I will let u know what happens. .
. Doctor Stix..0 -
Thanks whippetmom!! I sent you a pm with pictures. I have an appt with PS tomorrow morning 9 am cst time. I am sure I will hear "looks good, looks good." and be sent on my way.
Mary
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This is bottoming out. The implant has fallen below the IMF.
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mevanatta: I responded. You have a lot to discuss with him!
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sandra4611: Do you want to get a second opinion before you go under the knife again?
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Deborah, the surgery is this Friday so it's too late. Even if I saw a civilian PS, we couldn't afford to have surgery in a civilian hospital. Our Tricare for Life (military retiree insurance) would still leave 20%. I like my PS and don't blame him or doubt his skill. I just have a challenging case and very thin skin. <sigh> He is going to put in Alloderm this time. Not looking forward to it but am hoping it helps. I plan to wear a bra after this surgery. I've never had to wear one unless I was exercising, but I'm going to see how healing goes with a 24/7 bra this time. Maybe it will help.
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Thanks for posting that Sandra!! You gave us a wonderful example of this- I am assuming that is not you and a pic from the internet. This has been a great discussion. Hopefully people will learn from this. I will let people know what I find out at my next appointment- that's for participating in the discussion!!0 -
great examples you provided also Dive Cat. Thanks for participating in the discussion. I will let you know what happens... worst case scenario is that I end up with smaller implant I guess. And, I wouldn't mind that then I could get rid of this awful tattoo on the opposite breast- at least the majority of it. YET I REALLY DON"T want to start over..
Either way if I have to go through another surgery of smaller implants then it could be a win-win to get rid of this tattoo-reconstr. nipple that is a bit too lateral and too high!! - not terrible looking though0 -
Sandra, best of luck on Friday!
I know every PS is different, but there are some that really highly encourage use of a bra after surgery (mine included) - especially after a surgery where they will be reinforcing the bottom of the pocket with Alloderm. It both keeps the weight of the implants off the area while it heals (important with Alloderm and lower pocket repair) and helps with the formation of the capsule where you want it to be.
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I have bookmarked DiveCat's pictorial and explanation of bottoming out.
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Keep us posted sandra4611....Please check in when you are able after your surgery!
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Wondering if Divecat or Whippetmom or anyone else can help me understand the science of our implant pockets and how a bra can help shape. I'm 3.5 weeks out of exchange. My breasts/implants are a little too far apart. I have IMF incisions so have been wearing a gentle but supportive bra.
What i'm wondering is, what is this pocket the PS makes made of? Does it evolve in shape as its healing? Could an underwire bra actually alter the shape or placement of the pocket and move implants a bit closer together? or does the bra just push them together when worn?
I'm mystified by how the "pocket" works. Thanks for any help understanding.
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lalli,
I think whippetmom might know more than me on this, but basically the reason a bra can help shape is that it can help "close off" areas of the pocket while you are healing. The "pocket" is just the space created for the implant. A capsule also forms around your TE/implant (normal process of the body where there is a foreign body) within this pocket.
It is often recommended around here to wear a bra that pushes them "in", meaning
has some lateral support. My understanding is the idea behind this is to
help the pocket close and heal laterally to minimize risk of lateral
migration. Basically if your implant can still move around into that lateral space, it will keep the pocket open. If it can't, the area should heal and "close off" and reduce risk of lateral migration. In augmentation repair for either lateral or inferior migration, I often see bras as being recommended (including underwires) during the healing process - 24/7 - to both take the stress of the implant off the repaired area, and to help the pocket heal with scar tissue, etc to give the repair the best chance at long term effectiveness (once you have migration, you are at higher risk of it happening again as pocket revision is not perfect). I have also seen some plastic surgeons recommend augmentation patients with early signs of migration soon after surgery get into an underwire bra to hopefully close the pocket off to prevent further movement. It won't fix what has already happened, but it can in some cases prevent further migration.Think of..say, a pie before the top crust is sealed around the edges. There is all this empty space still where, if the pie is not sealed, the filling can fill and bubble out the side. You pinch and seal the edges and the filling now won't be able to escape out the sides. This is kind of like the pocket (the pie crusts), the implant (the filling), and the bra/wire (pinching off the edges). Kind of a bad analogy (I also debated comparing it to a pierogi being closed up!) but I could not think of another way to explain it right now!
It is however, very important that you are not wearing a bra that will "distort" the implant, pocket, or placement. You want a bra that supports the implants in their proper position. PS's are divided about underwires, and it can depend where your incisions are, but I also know that the PS who pioneered the direct to implant surgery puts his reconstruction patients with IMF incisions in underwire sports bras once their drains are out (1-2 weeks after surgery) to help with proper pocket formation/implant placement.
That being said, where your implants sit on your chest - in terms of space apart - also has a LOT to do with your own body anatomy - including your pectoral muscles and your ribcage. Here is a good link about this:
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And this is for Sandra, but I found this Q & A on realself about the wearing of bras after a capsulorraphy for bottoming out!:
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Thanks Divecat, That website was helpful. However it led me to more online reading and questions. And i liked your pie analogy....is the top crust the pec muscle and probably some alloderm? and what is it attached to (what is the bottom crust)?
My question then is will wearing a supportive bra after surgery prevent the implant from dropping a bit to a more natural look (some doctors on Realself seem to think so)??
And can an underwire actually move the pocket inward laterally a bit, or is that not possible?
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divecat those pictures pertains to cleavage are great examples. Thanks for posting
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has anyone had trouble sending pictures on this site?0 -
hi
I sent to your email Whippemom
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Stix, sorry to say, but the picture I posted was me - not something from the internet. The bottoming out is more pronounced on the left side where I've had so much trouble, but it's on the other side too. Here is a picture of the left IMF after my March surgery when another line of sutures was placed.
The implant has dropped again.
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