What's the best way to prevent bottoming out or double bubble?

Surgical expertise and good judgment are the most important factors.  Kenneth Hughes, MDLos Angeles, CA

I'm not sure there's much that can be done prophylactically except for wearing a good support bra. Implants placed under the pectoralis muscle can sometimes be pushed in an inferior direction creating bottoming out. You can't however permanently rest the pectoralis muscle.

in general, if you and your surgeon select an implant that fits the dimensions of your breast and is of the smallest size possible that produces a desired effect, your risk of bottoming out or double bubble, if the procedure is performed appropriately, will be minimized. Of course, no one can predict with certain that bottoming out will not occur. This usually is due to over-dissection of the inframammary fold either to lower the fold or to  accommodate a large implants, or due to selecting an implant whose dimensions are over-sized compared to your natural breast dimension. Robin T.W. Yuan, M.D.

Dear Valeriee,Breast augmentation is an excellent way to enhance the size and shape of the breasts.After breast augmentation, there is a small risk of implant inferior malposition, aka bottoming out.The best ways to prevent bottoming out are to select a good surgeon, to avoid large implants, and to perform proper aftercare including use of a supportive bra.Warmest wishes,Larry Fan, MD

This is more a function of the surgical technique and implant selection than anything that you can do as a patient. After a well executed operation, a good support bra is critical to maintain implant position for the first several months until the pocket is well developed.

The first step is to pick an experienced breast surgeon. In my opinion, the larger the implant the greater the chances for bottoming out especially saline implants because I believe saline is harder on your soft tissue long term. As to avoiding double bubble, go back to step one. Good luck!

Thank you for your question but at your consultation after a full examination and discussion of size your surgeon should be able to explain the risk in your specific situationDr Corbin

There are a number of what I consider myths of plastic surgery and specifically breast augmentation out there and my response is directed to fellow plastic surgeons as well as in response to your question. One myth is that the second crease in a double bubble deformity is caused by the old inframammary (lower breast) crease. Another is that the heavier the implant or saline-filled versus gel-filled implants will bottom out more. And one other is that support bras will prevent bottoming out. Bottoming out is stretching of the lower pole of the breast around the implant and specifically stretching out the inframammary crease level so that the distance from the nipple to the inframammary crease is too long relative to the distance from the nipple to the medial border of the breast. This can occur without a double bubble deformity and in my experience with properly sized implants is caused by patient tissue reaction factors, not the weight of the implant. The factors that determine and maintain the inframammary crease level are also not completely understood and controllable. It's possible for one side to stretch or bottom out and not the other. In general, a bra to support the inframammary crease level until it is healed after the augmentation is important but after two weeks it should be healed and efforts to maintain it with a bra seem futile. Bottoming out is corrected by reestablishing the inframammary crease at the appropriate level and requires an open procedure through the inframammary crease.Double bubble deformity is caused by the lower edge of the pectoralis muscle that has been released off the chest wall to get under the pectoralis muscle attaching and pulling on the fascia (connective tissue) that becomes attached to the breast and skin over it. This is best prevented by a dual plane release of the pectoralis muscle during the creation of the implant pocket so that it is no longer in the lower pole of the breast. This should be done to correct the problem as a revision as well. It is possible to have just bottoming out or just double deformity or both. If both then both the pectoralis muscle and the inframammary crease level need to be addressed in a revision. Other causes of bottoming out and double bubble include too wide (not too big) an implant that will not fit properly behind the breast and approaches to placing implants other than through inframammary crease incisions that do not allow for adequate dual plane release of the pectoralis muscle or controlling the inframammary crease level. The simplest and best approach both short term and long term is an inframammary crease incision to start with, particularly if the distance between the nipple and crease is short relative to the distance from the nipple to the medial border of the breast. Round implants need this distance to be the same. The measurement is made preoperative using a relaxed measurement for the medial distance but with the vertical distance measured under tension. The inframammary crease incision is then made where the crease will end up rather than where it starts. It is not lowered if it doesn't need to be.I would agree with the advice to find a plastic surgeon who is experienced with sizing implants properly, releasing the pectoralis muscle with dual plane technique, and controlling the inframammary crease level with an inframammary crease incision. Two weeks of an elastic band of the bra in the inframammary crease should be adequate to get it to heal properly.

Your inframammary crease or fold beneath the breast is your best defense against bottoming out or double bubble deformity. If at all possible, the crease should not be disrupted except under certain situations. Unfortunately some surgeons routinely lower the fold. The use of a specific underwire bra for 3 months in my practice has also completely eliminated the issue of bottoming out or lateralization of the implants.

If the distance from nipple to crease beneath the breast is sufficient, then "respecting" the crease and avoiding disruption to it will help, and additional anchoring sutures to set the crease can help. If this distance is not sufficient, then the crease will need to be lowered (otherwise leaving the distance short will cause the nipple to be down-pointing), and efforts should be made to set the new crease by anchoring it with sutures to discourage later "drop-out" of the implant below the level of the new crease location.  Bottoming out and other stretch deformities may develop over months even if these steps are taken, and textured surface implants may hold their position better and further reduce the risk of drop out.  I also have my patients wear a bra with a firm fitting band in the crease area to further help support the inframammary crease during healing.  Larger, heavier implants are also at higher risk for causing drop out due to the effects of gravity on the implant.