What caused the double bubble that I've had with my breast augmentation, and what should be done to correct it? (Photo)

I have been an enthusiastic practitioner of partial submuscular location of implants (incorrectly though popularly called "dual plane") during the first 10 years of my senior career, and no one of my patients experienced the dynamic double bubble or animation flex deformity. Howeever it is already 10 years now I moved to the subfascial plane of placement and I and my patients could not be happier (minimal pain, complications rate close to real zero, quick return to normal life, long term stability, etc, and of course the conceptual impossibility to sufery animation flex deformity, however such dynamic muscular deformity only happens in not correctly done submuscular procedures).
The dual plane is producing such horrendous issue because the surgeon fails to know the essentials of surgical anatomy of breast augmentation, as simple and terrible as it sounds; the animation flex deformity is NOT caused by a list of excuses and justifications like, among others, the following ones: (recorded from my own revision patients' stories told to me in office)
-"your muscle is too strong to cope with the implant"
-"you doo too much workouts, slow down or quit from gym"
-"your body rejects the implants"
-"seems an unxeplanaible and unforeseeable adhesion has been formed there"
-"oh you have capsular contracture, naughty implants"
-"how you dare to offend my reputation and skills! this result is the best possible"
-"your breasts are this ugly, you are bad lucky with your anatomy, I'm not at fault"
-"eeehm... eeer... the result is awesome, contratulations, you are discharged"
-"____________" (fill at your own, many others...)
And... beware! the technique is not to blame, a partial submuscular placement NEVER produces this deformity unless its executioner fails to do it correctly, ever.
I'll try to put it shortly and plain so that anyone can get it, even any colleague in need of professional updating:
-the pectoralis major muscles has tendinous insertions (attachments) at the humerus bone (arm, near the shoulder) and at the chest; I guess we all know what the pectoralis muscle is used for so I don't extend over this
-the insertions of the pectoralis muscle take place at the clavicle (collar bone), rib cartilages from 1st to 7th and horizontally at the osseous rib arcs of 6th and/or 7th (there are variations); well, pay attention now: these horizontal attachments are the cornerstone... the core... the key... the pitfall of the animation flex deformity (dear reader... stay tuned, the answer comes next)
-the lower border of the pectoralis muscle is, as mentioned above, attached to the bone arc of the 7th rib; when we do a submuscular placement of breast implants there are two options, one banned, proscribed and abandoned which is the "totally submuscular placement", and the second acceptable and efficient (though unnecessary and and unjustified nowadays, the golden standard is the subfascial plane) which is the "partially submuscular placement"
-when placing a breast implant TOTALLY under the muscle you create a grotesque deformity called "elevator breast" or breast implant animation deformity; as sounds obvious when the implant is totally embraced by the muscle every pectoralis contraction pulls up from the prosthesis up to the clavicle... therefore the implant is "dynamic" but not the breast, neither the muscle itself, the muscle is not released from the rib insertions and works as normal, the breast tissue does not experience traction, however the implant is submitted to powerful forces deforming it and raising it; that is why this technical option should NEVER be used, apart that the constant rubbing of the silicone against the ribs produces and augmented wear leading to very very early implant rupture; finally the totally under the muscle placement makes anatomically impossible centering the implants beneath the nipples, they alwas ride too high even without pectoral contraction, with pectoral contraction they go up close to the neck or armpit, literally
-when the implant is partially placed under the muscle in a CORRECT MANNER the surgeon releases the attachments of the pectoralis to the ribs at its lower and part of the inner borders, BUT... and this is an important but... ALSO has to release from the fascial ligament joining the lower border of the pectoralis muscle to the breast tissue and skin; this natural ligament (all women are born with it) is not a problem ever unless the muscle is freed from the ribs, since when the lower end of the muscle is firmly attached to the ribs its contraction does not raise the muscle and dose neither raise such ligament; and... why is the lower border of the pectoralis freed from the ribs? because otherwise we would produce an horrendous and problematic totally submuscular technique (read previous item)
-so, we have the dual or partial submuscular plane in which the lower border of the pectoralis muscle is disinserted from the ribs and also such muscular lower border is freed from the breast tissue, allowing free gliding of the lower border of the muscle during muscular contraction and thus preventing any distortion or deformity: the muscle does not push the implant upwardly and does neither pull the lower breast pole up by traction on the fascial ligament which links muscle and breast skin; however...
-...IF THE SURGEON FAILS TO RELEASE THE BREAST-MUSCLE LIGAMENT the lower end of the pectoralis muscle will glide free upwardly escorted or followed by the lower breast skin due to anatomical solidarity, and this is the ONLY cause of the animation flex deformity
-as brief summary: the totally under the muscle location produces dynamic IMPLANT deformity, in which the prosthesis is displaced up with the muscular contraction causing a grotesque deformity but the muscle and the breast do not ascent or experience any kind of direct deformity (muscle, ribs and breast tissue stay solidary en bloc); the incomplete and erroneously done partially under the muscle location (aka dual plane) produces dynamic BREAST deformity, in which the lower end of the muscle is freed from the ribs but not from the breast tissue, therefore during contraction the lower end of the pectoralis ascends pulling its cutaneous insertions and splitting the lower pole into two halves, pulling up from the breast but not from the prothesis (muscle free from ribs but breast tissue and muscle stay solidary en bloc); in the properly done partially under the muscle location (aka dual plane) there is no deformity, given the lower end of the muscle is free from both, ribs and breast, and glides smoothly between breast and implant free of adhesions when it is contracted during its daily use; needless to say all these disquisitions are pointless in the modern, highly recommended and awesome subfascial technique of placement
IMHO if a surgeon is not able to understand such a basic concept he needs to refresh his skills before going one with breast augmentations by attending few colleagues ORs to update his concepts; we are talking about concepts developed about 20 years or longer ago.
But that's not all; the erroneously done dual plane producing animation deformity always leads to a progressive onset of other subsidiary deformities; not only talking about the split lower pole and the dynamic double bubble; over the following months of years after surgery the breasts develop:
-lateralization of implants, due to the muscular contraction conflict
-due to same reason, lowering or bottoming out of implants
-due to the former ones, empty cleavage and side boob deformity
-as as direct consequence or part of the former, lateral and lower expansion of the initially carved breast pocket, including skin over expansion
-due to the side boob commonly patients suffer chronic pain or sensation loss in the breasts due to the intercostal nerves compression neuropathy
-eventually severe psychological distress and desperation to seek "creative" or revolutionary solutions to the dynamism
The solution to animation flex deformity is the simplest one can imagine, actually is the same than the prevention of its occurrence... guess which one? correct: if you (surgeon) perform a dual plane don'r forget to release the congenital ligament between the lower muscular border of the pectoralis and the breast tissues, just it!
So breast revision in your case has 100% success rate with a very very simple surgical gesture: surgical splitting of the muscular ligament to the breast, no more than 15 min surgical time each breast... 100% success as long as the revision surgeon has experience and understanding of the problem; this can be accomplished keeping the same plane (partial submuscular, acceptably but criticizable) or by means of conversion to subfascial plane (my choice).
Unfortunately that is not all, now comes the correction of the aforementioned subsidiary deformities, and a complex multipoint capsulorrhaphy has to redefine the breast pocked and allow closing the lateral excess tailored by the animation deformity and also get rid of the lower over expansion or muscle-induced bottoming out by raising the submammary crease to a proper position.
I strongly recommend using anatomical shaped implants, filled with cohesive (4G) or ultracohesive (5G) silicone gel and macrotextured or polyurethane coated at the shell to provide the highest grade of tissue adhesion and capsular contracture prevention.
See the link below to find few cases of my own practice very similar to yours which I had the opportunity to operate successfully on, sharing a lot of common features with the technical problem you have posted.
You'll see they are shockingly similar to your case... this technical fault is unfortunately very common and its deformity always very similar; on the good side its correction is always the same successful if the hands are proficient and talented.
Seek the help of a good expert in revisions, capsulorrhaphies and modern breast implants. Difficulty 8-9 out of 10 in breast revisions. Surgical time 4-5 hours.
Other treatments to this issue you might read online or might be offered to you are not working or can even worsen your situation, even precluding future repair.
If you wish better grounded opinion well lit, focused and standard images have to be assessed: frontal, both lateral and both oblique views, also from underneath.
Feel free to request any additional information from me.

It appears in your case that the implants had too large of a base diameter so your surgeon released the bottom edge of the breast (inframammary fold) in order to center the implants. You may have had a slight tubular shape, with a short nipple-to-fold distance, which predisposes to this type of problem. You will likely require a correction with capsulorrhaphy to raise the fold, and switch to either smaller implants or an anatomic shape.

Looking at your photos, you do appear to have implants that are too
big for your chest. They have also been placed too low on your chest.
Thirdly, although the implants would have needed to be placed below your
orginal infra mammary crease, the constriction in the crease should
have been released internally to minimise the effect. You would be
better off with smaller implants and reconstruction of the inframammary
fold. 
For optimal outcome, please consult a fully qualified plastic surgeon, who
has specialist qualification in plastic surgery 'FRCS Plast' after having being
trained adequately in the field of plastic surgery, is registered on the
'Specialist register for Plastic surgery' with the General Medical Council and
has been considered competent enough to be a member of the 'BAPRAS' (British
Association of Plastic Reconstructive and Aesthetic Surgeons) and 'BAAPS'
(British Association of Aesthetic Plastic Surgeons) at the least.

Dear ally_davies,
though rare, some women who undergo breast augmentation will develop a minor deformity known as a “double bubble,” in which additional folds appear underneath the breasts due to the implant accidentally shifting or contracting post-surgery. In most cases, the implant simply slipped too far down the chest wall and traveled behind the breast inframammary crease (the area where the lower breast meets the chest), instead of moving forward to fill the breast cavity. If left untreated, the lopsided implant will form unnatural indentations, resulting in an odd “four-breast effect” rather than the full, rounded chest the patient initially desired.
Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Unfortunately, you have not provided before photographs or told us your bra size.  The double bubble is caused by too large of implants.  Since a large implant was placed, the inframammary fold had to be lowered.  What you are seeing now is the old inframammary fold on top and the new inframammary fold on the bottom.  Also, your nipples are pointing upward and outward.  You will need a revision with smaller implants or explantation and fat transfers.Best Wishes,Gary Horndeski, M.D.

Thank you for the question and pictures!! A double bubble can be cause for many reasons. In your case is that the diameter of the implants is too large for your chest, which caused your fold to drop. 
The best solution may be to have those implants removed and replaced with smaller ones.
Please follow up with your surgeon.
Good luck!
Dr Quiroz!

It seems from the photos you provided that the constriction band has not been fully released in addition to have an implant which is too large to the footprint of the breast. I do think that you will benefit from having a smaller implant in addition to either re release of the constriction band and reconstruction of the inframamary fold.

Thank you for the question and photos.I do see your concern.  A "double bubble" is a cosmetically undesirable circumstance for patients with breast implants, which occurs when the breast fails to take on the shape of the implant, resulting in the appearance of a visible line showing a separation between the bottom edge of the implant and the bottom edge of the natural breast.  Sometimes, in situations like yours, the appearance of the breast improves over the course of the first several months; sometimes, additional surgery may be necessary to improve the outcome. Generally speaking, some factors that may increase risk of "bottoming out" and/or double bubble formation include the need to "lower" the inframammary fold (disruption of the patient's natural supportive anatomy); this dissection (or over dissection) may predispose a patient to breast implant displacement complications.  Utilization of a breast implant that is too large for a patient's frame may also be problematic.Your plastic surgeon will be your best resource when it comes to better analysis/information and good advice.  Best Wishes.

Thank you for your question.  The likely cause of your result is that the base diameter of the implants is too large for your chest, which caused your fold to drop. The lower crease is your new inframammary fold, and the upper crease is your old fold.  The best solution may be to have those implants removed and replaced with smaller ones.  

I would allow more time to pass and see how it looks in another month or two. If you are unhappy then the implants can be removed and replaced with smaller implants or the implants can be moved to the sub glandular position (above the chest wall muscle).