Best practice for correction of bottoming out? (Photo)

Question

My PS suggested placing a few sutures to help correct placement of my left implant but said it would be done under local anesthesia in the office. Is this common practice? Would the risk of infection not be super high with this procedure? Is it possible to have this corrected under general anesthesia in the OR? Is it likely that my implant will continue to fall out of the pocket if I do not choose to have it repaired? Photo progression shown for comparison.

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question.  The
best advice you can receive is from an in-person consultation.  If this is going to be corrected, it should be done the right way.  I would recommend performing this under general anesthesia and using a galaflex internal sling sutured to the periosteum of your ribs in order to bring up the entire implant pocket.   Make sure you specifically look
at before and after pictures of real patients who have had this surgery
performed by your surgeon and evaluate their results.   If your surgeon is not experienced with this type of surgery, then I  recommend
that you seek consultation with a qualified board-certified plastic surgeon who
can evaluate you in person.
Best wishes and good luck.
Richard G. Reish, M.D.  FACS
Harvard-trained plastic surgeon

Nelson Castillo, MD · Answer

Thank you for sharing your question and photographs.  In patients who have good quality tissue bottoming out can be corrected with a procedure termed a capsulorrhaphy.  This technique uses a series of sutures to narrow the implant pocket along the outer and lower portions to place the implant into a higher position.  This repair needs to be performed in an operating room for risk of infection to your tissues and/or the implant. If your tissues are not strong enough to support the implant an internal scaffold or bra can be sewn in to help take tension off of your tissues.  Because of the options available to you, be sure to see an ASPS board certified plastic surgeon in consultation to discuss.  Hope this helps.

Henry Wells, MD · Answer

This is usually addressed with a lower pole capsulorraphy.  The capsule can be cauterized to tighten it, then over sewn with sutures. Frequently, an upper pole capsulotomy is done to open the upper portion of the pocket to allow the implant to move upward. If this is not successful or not appropriate, Strattice or some other tissue or synthetic  matrix may be used to reinforce the lower pole. If the displacement is mild to moderate the capsulorraphy usually works. It is possible to revise this under local in the proper setting.

Richard P. Rand, MD, FACS (retired) · Answer

I would suggest that the surgeon who plans to do just a couple of stitches under local isn't preparing themselves or you for the best chance of success. The extra capsule that the implant now sits down in needs to be obliterated, sutures need to be placed, and the top of the pocket needs to be certain to have enough room to allow the implant to go back up.It might need to be opened up for that too.  Otherwise it will be pushed down again. I would personally want to do this in an OR under general anesthesia.

Marc J. Salzman, MD, FACS (retired) · Answer

When a breast implant migrates below the original placement location with the bottom of the implant just above the infra-mammary crease, we call this “bottoming out.” There are several causes of this downward migration of the breast implant. Usually, some attempt had been made to lower the crease to accommodate a breast implant whose base diameter is larger than would otherwise fit in the natural breast. In doing so, the anatomic attachment of the skin of the breast to the chest wall can be obliterated. There is then nothing to hold the implant up. With the weight of the implant, and constant gravity, maybe lack of support by lack of wearing a bra continuously, the implant can settle downward. One of the earliest symptoms, I see in patients seeking revision, has been the feeling that the breast has to be constantly adjusted or just feels heavy. We look for the incision line, which was previously placed at the crease, to have migrated upward onto the breast. When we see this early on in the postoperative phase, it will never get better with time and will require a secondary repair. While some plastic surgeons may rely on suturing techniques only, I have found that unless we un-weight the implant by making it smaller or strengthen the tissues below by making them less stretchy, that the same implant, with only sutures placed on the bottom of the pocket, will, over time, recur it's bottomed out position. I have used part of the capsule as well as the lining of the deep muscles and tissues over the ribs in the capsule beneath the breast implants to rotate upward to hold the breast implant in a higher position and therefore obliterating the extra space that has been created between the correct infra-mammary crease and the one created by the downward displacement of the implant. I call this a three flap technique, as the skin, the capsule and fascia (lining of muscles), as well as a dermal flap all contribute to creating a hammock like support of the lower portion of the pocket. When these tissues are insufficient to hold the implant up, or a previous attempt has been made with sutures, I will oftentimes rely on the addition of another type of tissue called an acellular dermal matrix of which my preference is Strattice or Galaflex. This Strattice, or pigskin, does not stretch and can be sewn in to the bottom of the new location of the crease to support it just like a hammock would. Although this is costly, I consider this an insurance policy against having to redo this again. I would recommend that you try and find a plastic surgeon with experience in revisionary cosmetic breast surgery. Good luck.

Best practice for correction of bottoming out? (Photo)

Answers (5)

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