October 14, 2026 | Breast, Breast Augmentation Revision
Rippling is the wave you see on the upper or outer breast when there is not enough tissue between the skin and the implant. It shows up in thin, athletic patients, and it can show up late, after the swelling is gone and the body has changed. What follows is a revision visit from my El Paso office, nearly as it happened, identifiers removed.
“You can feel the ripples”
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.”
“Would a different implant change anything?”
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.”
“Why not under the muscle?”
Her: Most of my friends who work out, they get it under the muscle. Maybe it could have helped me. 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.”
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.”
“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.”
“Will the fat stay?”
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.”
“What does switching under actually involve?”
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.”
“Do I do everything at once?”
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: 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.”
Her: I think it was within two years I can decide, right?
Me: “Yeah, we don’t have to do it today.”
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.”
Why most of my implants go over the muscle now
Patients ask why I did not just put it under to begin with. Here is what I told another patient that same week: “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 the condition that makes over the muscle work: “The good thing is you have enough tissue that you’re not seeing the rippling.”
Rippling is a tissue problem. Thicken the tissue, change the implant, or change the plane. The right answer depends on how much of you there is over the implant, and that is what the exam is for.
Dr. Agullo is a double board-certified plastic surgeon, a Mayo Clinic fellowship alum, and a Clinical Associate Professor of plastic surgery at Texas Tech University Health Sciences Center. Book a consultation.
Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at drworldwide.com.
#StayBeautiful
