I think my right breast implant has bottomed out. I noticed the difference within a month of the original surgery. When I lay on my back the right implant falls into the axillary area. Both breasts are very soft and the implants can easily be moved around. Was this the fault of the surgeon, and if so, what type of fee reduction should I ask for on his part for the revision? It has been 18 months since the original surgery, but he has been aware of the issue since 3 months post-op. Thanks!
Bottoming out of Breast Implants the Fault of Surgeon?
Doctor Answers 17
The pocket was likely made too big
When a breast implant moves or falls into the axilla it is usually because the Serratus Anterior muscle was violated during surgery in the case of a submuscular implant. If a subglandular breast implant was done, then the pocket was made too large and extended too far laterally.
This is especially true if the problem was noted in the first month or so after surgery.
You need to review your photos and discuss this with your surgeon.
Revisions are expensive and my own view is that expenses should be shared. When I am faced with a situation like this I ask the patient to cover the OR and Anesthesia fee and I do not charge a surgical fee-however you need to discuss this with your surgeon. If the problem is that your tissues are prone to stretching or some other factor was involved, such as post operative trauma, exercise or weight lifting before you had healed, then you may bear the responsibility.
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Consequence of Implant Pocket too Large
Without photos or an exam, it is difficult to comment as it is unclear the exttent of your problem. That being said form your description it appears that the pocket was made too generous rather than bottoming out (implants too low). The best tact would be to have a candid discussion with your plastic surgeon. Although there are rarely implied or actual guarantees of surgical results as plastic surgery is an inexact science, most surgeons will be reasonable and work with you to acheive a mutually agreeable solution.
Is it bottoming out?
Bottoming out to most surgeons means that the implant settles or slides below the inframmamary fold and the nipple areolar complex looks too high. What you describe is a lateral pocket overdissection or tissue stretching that allows the implant to slide laterally. Unfortunately, it is pervasive thinking in our society, that if something is not "perfect" one must find someone to blame and ask for renumeration. It is most likely no one's fault. You do not state how thick your skin is, are there any stretch marks, were you pregnant before, what size implants you got, silicone gels or saline? All these can be a factor in your results. Hopefully your surgeon discussed these issues with you during the informed consent process. To get back to your question, it seems that your right implant pocket is more lateral than the left one. You will need another surgery to close it down and make it it more symmetrical. Since it it is only on one side, I charge 25% of my surgical fee, but the patient is still responsible for the operating room costs and the anesthesia fee. If the implant is damaged during surgery, than the patient will need to pay for another implant as well.
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Bottoming out of Implants
Any time that a procedure is performed there are risks that are involved and some are less frequent than others. Even if a complication occurs that was a known risk, rather than look for blame or fault, most plastic surgeons will work with the patients to decide what the best procedure to resolve the issue is and usually give a significant reduction in the surgeon's fee (he may have no control over the facility fee and anesthesia). This is not an admission that either the patient or the surgeon was at fault, but that there was an outcome that wasn't anticipated. I usually reduce the surgeon's fee by at least 50%, but again it is based on what needs to be done, how involved it would be, , etc.
Who is to blame for implant malposition
There is an art to surgery and unfortunately it is not an exact science. We all expect perfection and if it is not delivered then it is easy to seek to blame someone. When things do not go as planned then it is usually a combination of factors and not just one condition that leads to these problems. Blame aside, you most likely need a capsular repair to keep the implant from falling off to the side. We give our patients a copy of our re-operation policy which details that there is no surgeon charge for the first year but we do charge for anesthesia fees, or fees and replacement of the implant if ruptured. As a plastic surgeon we strive for perfection each and every time no one wants an office of dissatisfied patients requesting secondary surgery.
Bottoming out of Breast Implant?
One of the most common complications after breast augmentation surgery is implant malposition. This occurs when the implant is in an incorrect position on the chest wall. This may include incorrect position of the implant superiorly (“riding high”), inferiorly (“bottoming out”), medially (“symmastia or uni-boob”) or laterally (falling outward into the axilla).
Bottoming out involves inferior migration of the implants. This causes the nipple areola complex to appear too high on the breasts. Also, the distance from the areola to the inframammary fold is too great. This is corrected by “raising” the inframammary fold using internal sutures. This is done after careful measurements are made from the areola to the “new” inframammary fold.
Lateral (outwardly) displacement of the breast implants can be corrected using an internal suture technique decreasing the size of the pockets and moving the implants toward the midline.
I hope this helps.
You need a surgical revision to fix the breast asymmetry
I certainly appreciate your concern. It is time for you to have a heart-to-heart discussion with your plastic surgeon regarding your post operative results. Unfortunately, you are in need of a surgical revision. There is obvious breast asymmetry do to mal-positioning of the breast implants. I would recommend that you return back to your original plastic surgeon and discuss your options at length. Of course, fees will be a topic that needs to be addressed. I’m sure that your plastic surgeon will work with you on this.
Lateral displacement (movement into armpit) of implants can be repaired
Movement of the implant into the axilla is not necessarily a sign of bottoming out.
In my practice, I often see this in a few repeated scenarios:
- patients who have submuscular placement of the implants and then return to agressive pectoralis strengthening exercises which causes lateral displacement of the implant with muscle contraction
- patients with a pigeon chest deformity called pectus carinatum
- patients with lax tissues and subglandular placement.
In many instances, I have repaired this by performing a lateral capsulorrhaphy and ask the patient to cover the anesthesia, OR, and any implant fees.
Bottoming out actually refers to the implant falling below the fold. If the implant is going into the axilla, the pocket obviously has enlarged. It is often not the fault of the surgeon. Any reduced fee should be discussed with the surgeon but not to be definitely expected.
Usually a combination of factors
Bottoming out or stretching of the lower portion of the breast causes the implant to appear lower than desired. This can be simply a results of skin type which is prone to easy stretching and looseness. A non-surgical example would be pregnancy where some women have no residual loose skin after giving birth and some women need a tummy tuck due to the loose skin. Another factor would be the size of implant chosen. The bigger the implant, the more chance the skin will stretch. Every surgery has risks and when choosing an implant size, you have to consider the trade-offs. Also the pocket created during surgery can be a factor for "bottoming out". However, if you have a very flat chest and no discernable breast fold, then that again puts you at more risk for the implant being positioned lower than desired. Most plastic surgeons would work with you to get you the realistic results you desire. Discuss with your surgeon what fees are involved in a revision. Typically you will have to cover the anaesthesia and facility fees. Also consider the risks involved in the revision such as higher chance for capsular contracture and is your situation bad enough to warrant a revision surgery. Remember to always have improvement in mind and not perfection. Good luck.
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.