Possible bottoming out. How to go about revision / is the surgeon at fault? (Photo)

I got my breast implants a little over a year ago. We agreed on three sizes (325cc, 350cc, and 375cc). Before surgery I told him to go bigger rather than smaller. I woke up with 275cc implants and was unhappy with the size being too small. After taking the bandages off, I noticed my right breast was lower and I could see a crease where You could see the actual breast tissue was apart from implant. My surgeon told me he agreed but that it would get better but it has only gotten worse.

Doctor Answers 7

Double Bubble

I recommend tightening your breast capsule and re-establish your IMF. I recommend an in-office examination as well as a detailed discussion with a board-certified Plastic Surgeon certified by the American Board of Plastic Surgery.
Best wishes!
Dr. Desai
Harvard Educated, Beverly Hills & Miami Beach Trained, Double-Board Certified Plastic Surgeon

Dr Kayser

Thank you for your question. Unfortunately you have what is referred to as a double bubble deformity. This occurs when disruption of the natural breast fold occurs in order to accommodate an implant. In patients whose breast fold to nipple distance is very short, placement of an implant which is larger than this distance, creates this deformity. It is certainly reasonable to give yourself time to settle down as some of this deformity as it may relax in the next 6 to 12 months. However, if it does not, revisional surgery such as release of the constriction bands or implant exchange may be required. I would encourage you to return to your plastic surgeon and have a full discussion with him as I am sure he is more than happy to make sure that you are happy with your results. I hope this helps and have a wonderful day. Dr. Kayser - Detroit

Melek Kayser, MD
Detroit Plastic Surgeon
4.9 out of 5 stars 31 reviews

Double bubble

It looks like you have a double bubble.  It would be interesting to see your preop photos. My guess is that the one with the DB had a higher fold.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Lowering the fold

Your old breast fold is the crease you see. You had to lower the fold to get bigger breasts, the crease has to be really released during surgery and even then a crease is sometimes visible. Yes you look a bit bottom heavy with more breast implant below the nipple then above and your right fold a bit low. Bigger implants and repair of the fold and release of the crease just a tiny bit is what I would offer most likely. Good Luck!

Gregory T. Lynam, MD
Richmond Plastic Surgeon
4.9 out of 5 stars 53 reviews

Possible bottoming out. How to go about revision / is the surgeon at fault?

I am sorry to hear about your concerns after breast augmentation surgery. Although frustrating, the complications you have experienced are not necessarily anyone's “fault”. Breast implant displacement can occur despite the procedure being performed correctly.

It looks like you have "double bubble" and breast implant bottoming appearance after your revisionary surgery. 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. Double bubble "deformities" may be more striking (visible) when breast implants have bottomed out.

There are several options when it comes to revisionary surgery to improve your outcome. One option is to eliminate the pull of the pectorals major muscle either by completely releasing it or by suturing the muscle back down, thereby placing the breast implants in the sub glandular position. Patients who choose to have breast implants placed in the sub glandular position should have enough breast tissue coverage to allow for this conversion. There are disadvantages of placing breast implants in the sub glandular position (such as increased risk of breast implant encapsulation) which should be considered as you make your decisions.
Another maneuver that may be helpful is raising the inframammary fold using capsulorraphy techniques. Sometimes, depending on factors such as quality of skin along the lower breast poles, additional support provided by acellular dermal matrix or biosynthetic mesh may be very helpful. I have also found the use of acellular dermal matrix very helpful in cases where the skin/tissues are very thin and in cases of recurrent breast implant displacement. The acellular dermal matrix helps improve contour, improves irregularities caused by the underlying breast implant and/or scar tissue, and provides additional support ("sling" effect) for the breast implants.
I hope this, and the attached link, helps.
Best wishes.

Bottomed out implant

 From your photographs, it does appear that your breast is bottoming out.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 just 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. 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.

Marc J. Salzman, MD, FACS
Louisville Plastic Surgeon
4.7 out of 5 stars 44 reviews

Right Breast Implant Bottoming Out.

Hello, and thanks for the question and the photos. From the pictures, it does look like the right breast implant has bottomed out and sits well below the original infra-mammary fold. This leads to the increased fullness at the bottom of the breast, the decreased fullness at the top of the breast, and the higher nipple/areola position. There is also a "double bubble" deformity in that the implant creates fullness below the breast, and the breast tissue sits higher on the implant, creating a second area of fullness. This is where you noticed the breast tissue apart from the implant. Sometimes this kind of thing can be attributed to over dissection of the pocket, or using an implant that is too large for the tissues to support, but more often it is unpredictable and occurs even when everything was done carefully and correctly.
The good news is that this can be repaired. This involves going through the same incision, removing the implant temporarily, and removing a crescent shaped section of the lining of the implant pocket (the capsule) at the lower aspect of the breast along the infra-mammary fold, then sewing the free edges of the pocket together. This raises and tightens the fold from the inside, and reduces the area of the lower pocket. The implant is replaced and is now sitting higher, back under the breast tissue.
Some repairs also utilize sheets of biologic material (Acellular Dermal Matrix, or silk constructs called Seri) to provide additional support, but your implant is fairly small, and a repair without these materials is likely to work. Speak to your surgeon about this.
I hope this helps!

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