Breast lift

Subjective:
Chief Complaint:
Breast implant revision and asymmetry.

History of Present Illness:
The patient is a female who underwent breast augmentation surgery approximately three years ago and is now presenting for a follow-up consultation regarding potential revision surgery. The patient expresses concerns about asymmetry and the positioning of the implants, particularly on the right side, where the implant has not descended as expected. She reports a history of significant weight loss since the initial surgery but states that her weight has been stable recently, with only a minor fluctuation of a few pounds. The patient has completed a short course of Ozempic for weight management and does not plan to continue its use in the near future. She is considering options for revision surgery, including addressing the implant pocket and potentially resizing the implants, as well as reducing the areola size for symmetry. The patient is aware of the risks associated with the proposed procedures, including implant malposition, double bubble deformity, and scarring, and is seeking further information and cost estimates before making a decision.

Past Medical History:
Jane Smith reports a history of significant weight loss since her initial breast augmentation surgery. No other chronic illnesses or significant medical conditions were discussed during the encounter.

Family History:
No family history relevant to the current condition was provided.

Social History:
Jane Smith is not planning on any major weight swings. She does not have a family doctor managing her Ozempic use. No additional information regarding tobacco, alcohol, recreational substances, occupation, lifestyle habits, or marital status was provided.

The Review of Systems:
Constitutional – No fever, chills, weight loss, weight gain, night sweats, fatigue, or weakness reported. Eyes – No double vision, no blurry vision, wears glasses. ENT – No hearing loss, dizziness, runny nose, nose bleeds, nasal septum deviation, or sore throat. Integumentary – No rashes, dry skin, or eczema. Cardiovascular – No chest pain, heart palpitations, dizziness. Respiratory – No shortness of breath, no cough, no wheezing. Endocrine – No known thyroid issues, no changes to appetite, no weight change, no tiredness or lethargy. Gastrointestinal – No nausea, vomiting, diarrhea, or constipation. No problems swallowing. No abdominal pain or bloating. Genito Urinary – No dysuria, hematuria, frequency, urgency. Musculoskeletal – No joint tenderness, redness or swelling. Neurological – No headaches or weakness, no history of seizures. Psychology – No changes in mood, no anxiety. Hematology – Denies easy bruising. Patient does not have capsular contracture. Patient does not have hard or painful symptoms on the lateral side.

Allergies:
No allergies were reported.

Current Medications:
Jane Smith has completed a short course of Ozempic for weight management and is not doing Ozempic long-term. No other medications were reported.

Past Surgical History:
Jane Smith underwent breast augmentation surgery approximately three years ago. No complications or issues with postoperative healing were discussed. No additional surgical history was provided.

Objective:
Physical Examination:
Not assessed during telehealth visit.

Test Results:
No information available.

Vital Signs:
No vitals reviewed.

OBJECTIVE:
Vital Signs: No vitals reviewed.
Physical Exam:

Breast/Affected area – Not assessed during telehealth visit.
General – Not assessed during telehealth visit.
ENT – Not assessed during telehealth visit.
Cardiovascular – Not assessed during telehealth visit.
Respiratory – Not assessed during telehealth visit.
Skin – Not assessed during telehealth visit.
Abdomen – Not assessed during telehealth visit.
Musculoskeletal – Not assessed during telehealth visit.
Neurological – Not assessed during telehealth visit.
Test Results: No information available.

Assessment:
Differential Diagnosis:
1. Breast implant malposition (right side): Supported by patient-reported asymmetry and lack of implant descent on the right side.
2. Capsular contracture (subclinical): Considered due to the presence of capsular tightening on the lateral side, though patient does not report pain or hardness.
3. Double bubble deformity: Risk discussed due to potential implant lowering below the inframammary fold.
4. Areolar asymmetry: Patient is considering areolar reduction for improved symmetry.

Impression:
Jane Smith is a female patient who is status post breast augmentation approximately three years ago and is now presenting for a follow-up consultation regarding potential revision surgery. The patient demonstrates a stable postoperative course with satisfactory overall aesthetic results, particularly on the left side, where the implant has descended favorably and achieved a natural contour. However, there is persistent asymmetry due to the right breast implant not descending as anticipated, likely secondary to capsular tightening on the lateral aspect. There is no evidence of capsular contracture, pain, or significant implant malposition at this time. The patient has experienced significant weight loss since her initial surgery but reports stable weight in recent months, with only minor fluctuations. She has completed a short course of semaglutide for weight management and does not intend to resume it in the near future. The patient is actively considering revision options, including pocket adjustment, possible implant exchange, and areolar reduction for improved symmetry. She is aware of the potential risks and is seeking further information and cost estimates before proceeding. No acute complications or urgent concerns are identified at this time.

Problem:
Breast augmentation revision consultation for right-sided implant malposition, asymmetry, and consideration of areolar reduction.

ASSESSMENT:
Impression: Jane Smith presents for evaluation of right-sided breast implant malposition and asymmetry following prior augmentation, with consideration of revision surgery and areolar reduction. She is aware of the risks and is seeking further information and cost estimates.
Problem: Breast augmentation revision consultation for right-sided implant malposition, asymmetry, and consideration of areolar reduction.

Plan:
Tests: No diagnostic tests or imaging were recommended during this encounter.
Plan:

- Procedure: Discussion of potential revision surgery options, including addressing the implant pocket on the right side, possible implant exchange (with consideration of increasing to 400 cc), and areolar reduction for symmetry. The use of GalaFLEX mesh as an internal support was discussed as a potential adjunct, particularly if increasing implant size.
- Follow-up: Jane Smith requested a cost estimate for the proposed revision procedure. Further management to be determined after patient reviews the quote and communicates her decision.

Surgical Discussion: The purpose of the surgery is to improve breast symmetry and implant positioning, specifically addressing the right-sided malposition and potential areolar asymmetry. Alternatives discussed include observation, seeking a second opinion, or limiting intervention to areolar reduction only. Risks and complications discussed include implant malposition (bottoming out, lateralization), double bubble deformity, need for secondary procedures, scarring, and aesthetic dissatisfaction. The potential need for GalaFLEX mesh and its associated costs were reviewed. General anesthesia would be used for surgical intervention, and the risks of anesthesia were acknowledged. Postoperative care instructions, wound care, and activity restrictions were discussed in general terms. Recovery expectations and the unpredictable nature of surgical outcomes in this context were emphasized.

Surgery Discussion:

- Purpose of the Surgery: The primary objective of the proposed revision surgery is to address right breast implant malposition and asymmetry by releasing the lateral and inferior capsule to facilitate implant descent, with consideration for implant exchange to achieve improved symmetry. Additional consideration is given to areolar reduction for enhanced aesthetic balance. Patient is not planning to increase implant size unless necessary during surgery.
- Risks and Complications: The patient was counseled regarding the significant risks associated with further manipulation of the right breast implant pocket, including but not limited to implant bottoming out, lateral displacement of the implant into the axillary region, double bubble deformity, and the potential need for complex secondary procedures such as internal mesh support (GalaFLEX), which may incur substantial additional costs. Risks associated with areolar reduction include hypertrophic or widened scarring, pigmentary changes, and possible aesthetic dissatisfaction. Patient is not planning to increase implant size unless necessary during surgery, which would otherwise increase the risk profile.
- Alternatives: Non-surgical alternatives were discussed, including observation and acceptance of the current result, as well as seeking a second surgical opinion. The option of performing only areolar reduction for symmetry, without altering the implant position, was also discussed.
- Follow-Up Care: The patient requested a formal cost estimate for the proposed revision procedure and will consider her options before making a decision. Further follow-up will be arranged based on the patient's decision regarding surgery.