Bottoming-out Repair and Augmentation Revision with Larger Implants

A 34-year-old woman 6 years after textured saline implant augmentation via an areola incision approach. That surgery resulted in partial muscular coverage of the implant with subsequent bilateral capsule contracture firmness and bilateral Bottoming Out, worse on the left, with upward rotation of the nipples as the implants have fallen and are no longer centered behind the nipples. These textured saline implants, partially under the muscle, were wrinkled, and felt quite firm and unnatural to the touch. In my experience, textured implants do not prevent capsule contracture, and they are intrinsically much firmer than smooth submuscular implants maintained in an oversized pocket. Textured implants also show rippling much more than smooth implants, and seem to have a much higher failure rate in the instance of textured saline implants. Bottoming-out repair was accomplished by internal soft tissue repair (capsulorrhaphy) without the need for Alloderm or other acellular dermal graft. The result remains stable at over 10 years. At the time of this repair the textured 225 and 250cc saline implants were replaced with 425 and 450cc smooth round implants, increasing volume, restoring shape and symmetry, and providing long-term stability to the Bottoming-Out Reconstruction.