How Best to Revise Implants That Have Bottomed Out?

I had saline implants placed above the muscle approximately 12 years ago. I now wish to have a revision surgery performed. I would like to eliminate the rippling that is currently occurring with the saline implants I have. What is the best implant for a natural, full look with minimal rippling? I really want to avoid the "bowling ball" look and would like a very natural appearance. What are the arguments for going above vs. below the muscle? Could my muscle have atrophied over time?

Doctor Answers (10)

Using a breast revision technique for breast implant bottoming out

+1

The rippling and bottoming out of an implant can be improved with a capsulorraphy and implant exchange.  The overall look of your breasts will be improved. 


Los Angeles Plastic Surgeon
5.0 out of 5 stars 49 reviews

Bottoming out repair

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I like to wait  at least 6 months prior to correction of inferior displacement of breast implants (bottoming out). This allows for the capsule tissue around the breast implant to have increased strength and hold sutures better (capsuloraphy)- I think this allows for improved chances of successful repair. Allograft reconstruction may also be helpful, especially if the implant malposition problem is recurrent.

In regards to implant pocket change, I think that exchanging the implants to the submuscular position at this time carries increased risks of complications.

 

Make sure you seek consultation with a board-certified plastic surgeon with significant experience with revisionary surgery. Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 780 reviews

PHOTO: Bottoming out Saline breast implant augmentation

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This seems to be well covered here but I wold recommend transition to a moderate plus silicone gel filled prosthesis with inferior capsulorraphy and prolonged wearing of a padded underwire bra for 6 weeks to support the repair

Otto Joseph Placik, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 48 reviews

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Rippling and bottoming out

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To correct the bottoming out, the folds can be reinforced and a capsulorrhaphy can be performed. As for rippling, it is tough because it relates to the soft tissue coverage.  Silicone gel impalnts tend to ripple less, and if need be  alloderm can be used to help.

Steven Wallach, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 17 reviews

Breast implant rippling and bottoming out

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To correct the "bottoming out," my general approach is to re-establish a higher inframammary fold by careful lateral and inferior capsulorrhapy with Ryan type sutures placed under general anesthesia.  This mandates removal of your current implants, surgical reconstruction of the implant pocket margins, and replacement of the implant.  

Regarding the causes and treatment of visible rippling, understand that currently available implants in the United States may all ripple to a degree.  Form stable implants awaiting FDA approval will not be prone to rippling.  Strategies for minimizing visible rippling include gel implants instead of saline, if saline is used perhaps slight overfilling, submuscular or dual plane implant placement, smooth surface implants, and smaller implants.  The higher the percentage of your final breast volume that is implant, the more your breast will behave like an implant, and that includes implant texture, and rippling.  If you are very lean, count on at least some palpable (although not necessarily visible) rippling, especially at lower outer edge.  Another possible strategy if you have the time, money, and risk tolerance is implant removal, fat grafting of the breast, and subsequent implant placement. 

Steve Laverson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 38 reviews

Bottoming out of breast implants.

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I recommend not going any larger than you already are and even consider going a little smaller.  Switching to a gel implant in the submuscular position is likely to address the rippling problem.  Your surgeon will need to carefully close off the lower part of your existing pocket to keep the bottom of the implant higher than where it is now.  I do this with closely spaced permanent sutures and require my patients to wear and underwire bra for two weeks, 24/7 to help this area seal off and prevent recurrent bottoming out.  Also, some surgeons are using dermis such as Alloderm or Stattise to help with rippling or recurrent bottoming out.  This material is very expensive and probably best reserved for really tough, recurrent cases.   

Lisa Lynn Sowder, M.D.

Lisa L. Sowder, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 46 reviews

Bottoming out

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This is a difficult dilemma.  As implants have existed for many years, we are seeing this problem more commonly.  Additionally, it is now the standard to place implants submuscularly.  It was more common to place implants subglandularly in the past.  In short, the more tissue that exists between the implant and the outside world , the better.  Ideally, the implants should be removed.  You may need a partial or complete capsulectomy (this involved excising scar tissue from around the implant).  A silicone implant is often a good option due to less rippling.  Then, either your own capsular tissue or a dermal matrix may be required to tether the implant behind the muscle and to stop it from returning to the subglandular plane.  When seeking the appropriate physician, please ensure that they have performed this case often.  It is not a simple fix. Good luck!

Jason R. Hess, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 8 reviews

Breast Implants Bottoming Out

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Time, large implants or over aggressive dissection can lead to bottoming out of breast implants. Saline implants are the most common cause of rippling and this is made worse when placed above the muscle.  The solution for you would be related to changing out your implants to silicone with the size to be determined, using some of the existing capsule around your current implant to support the new implant and placing the new implant beneath the muscle.  These operations are complicated so it is important to find someone who is skilled in revisionary breast surgery.

Best of luck,

Vincent Marin, MD, FACS

La Jolla Plastic Surgeon

Vincent P. Marin, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 26 reviews

Silicone gel implant will help but not 100%

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The main issue that you complain  is the rippling and also the bottoming out. The rippling can be corrected to some degree with silicone gel implants. You will need to have pocket revision to help with the bottoming out. The idea of the exchanging the pocket from sub glandular to sub muscular sounds good but can be challenging due to the muscle scarring from the implant.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
5.0 out of 5 stars 59 reviews

Breast revision recommendations

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It does apear that your implants have settled lower and would benefit from revision surgery. One of the ways to decrease implant visibility, at least in the upper and inner area is to move the implant to a partially sub-muscular position (called a site change). This could be accompanied by the use of an acellular dermal matrix, i.e. Strattice, in addition to suturing of the lower capsule to help raise the implant up. I know this sounds technical but I would advise you find a board-certified plastic surgeon close to you who has performed these procedures. I hope this helps.

Dr Edwards

Michael C. Edwards, MD, FACS
Las Vegas Plastic Surgeon
5.0 out of 5 stars 11 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.