The lower pole of my breasts have an indent. Have I Bottomed out? What is the next step? (photos)

Question

The lower pole of my breasts have an indent in them. It seems as if my breasts are hanging off my implant. Also, my breasts indent a lot more when I flex my pec , it's embarrassing. Is this normal? What is the process if fixing the bottoming out, surgically speaking. I am a fitness instructor so how long until I can do yoga?

Mark D. Epstein, MD, FACS · Answer

The crease on your breast is a little hard to appreciate on the photos you submitted, but it is suspicious for a double-bubble deformity. This is usually seen in breasts that are young, nulliparous (never lactated) and have a tight soft tissue envelope. Some surgeons believe that this has to do with the release of the lower breast crease. I have different opinion - in order to create a space underneath the pectoralis muscle for the implant, the muscle must be detached from the lower ribs. The muscle will naturally retract upwards for a couple of centimeters. Along this edge where the muscle edge rests, it now scars to the underside of the breast gland and pulls upwards on it, creating a crease in the lower pole of the breast. If the glandular tissue descends, the same result may occur. This has nothing to do with the fold (again - my humble opinion only).  The treatment for this is either:1. Create a new pocket above the muscle for the implant - therefore the muscle cannot pull on the underside of the glandor2. Convert the submuscular pocket to a Dual plane II or III which will allow the muscle to retract upwards and thus no longer pull on the lower pole of the breast.Bottoming out is a different problem altogether. There are two different subtypes and they may co-exist:For simplicity sake, lets assume the scar lies in the crease at surgery-1. The breast stretches and the distance from the nipple to the crease elongates. This is true bottoming out. If this is severe, correction is probably removing an ellipse along the crease which will lengthen the scar. This is rarely the situation alone.2. The upper chest skin just below the scar elevates off the chest wall and then is recruited into the implant pocket. This will result in the scar migrating upwards onto the lower pole of the breast, elongation and distortion of the lower pole of the breast and significant loss of fullness of the upper breast, sometimes even causing a "clothing emergency" as the areola can be nearly or partially exposed in some bras/bathing suit tops. Treatment here is to elevate the breast crease (inframammary fold) back to the original position.Both of the above can co-exist, but usually it is the second that is responsible for the unsatisfactory appearance of the breast.Proper treatment of implant malposition and pocket problems requires careful analysis of the problem in order to properly treat them.

Ryan Neinstein, MD, FRCSC · Answer

Sometimes when there is a mismatch of breast tissue width to implant width the breast can telescope like this without bottoming out, sometimes it corrects in time with the implant stretching the tissue

Beverly Friedlander, MD · Answer

Hi, It is important to know   when you had  your surgery, and whether you are happy with the size and shape of your breasts and whether this has happened on both sides. .  The decision to correct  a double bubble  and the type of surgery needed will be dependent on your answers. You ask when can you go back to yoga, so I get the impression that your surgery was relatively recent.  This is consistent with the red scar I see as well.  There is always swelling in the beginning.  It takes time for the swelling to dissipate and for the implants to settle.  The final position of your implants will dictate the best corrective procedure.   This may require a tightening of the pocket, the creation of a new pocket  or possibly as mentioned below, fat grafting.  Don't rush into anything as the tissue needs time to heal from the 1st procedure to allow for  a strong repair secondarily.   Your "double Bubble "has 2 components.  An incomplete release of the natural fold which is the indentation you see, and a descent of the implant below the fold.  An incomplete release of the native fold is not uncommon with a constricted breast. Your indentation with muscle contraction needs to be evaluated with an examination.  Some degree of indentation may be normal with a submuscular implant.   Your surgeon is the best person to answer these questions particularly if the breast was constricted preoperatively.  good luck  DoctorBev

Darryl J. Blinski, MD · Answer

You have a very minor "double bubble" effect that can be corrected via fat grafts and rigotomies. As for bottoming the posted photos do not demonstrate that...

Kamran Khoobehi, MD · Answer

The pictures show double bubble due to the release of the inframammary fold ligaments. Please see your surgeon for evaluation. You will need revision to correct this.

Steven Wallach, MD · Answer

It is difficult to say from the photos posted whether or not you are bottoming out.  An exam in person would be essential. Furthermore, some flexion animation issues can develop when under the muscle.

Mark Eberbach, MD · Answer

It does appear to me that there was an incomplete release of the pectoralis muscle from the overlying breast tissue or lack of fiber division in the constricted breast.  When you contract your chest muscles it pulls that hollowed ridge up and out.  If that is the case, revision surgery is likely necessary to separate the muscle from the breast tissue.  I would certainly give this time to resolve on its own before making any surgical decisions.  It can sometimes take several months for spontaneous improvement.Certainly you should go back to your plastic surgeon and point out your concerns and ask for help resolving them.  This kind of thing can happen with good surgeons and good surgery.  Use a calm approach when asking for help resolving it.

William G. Hart Jr., MD · Answer

The depression you are noticing in your breast is most likely the insertion site of the pectoralis muscle into the breast tissue which is then transmitted to the overlying skin. It is possible that this could improve with time. It is difficult to tell from the photographs you've provided. I would suggest you make an appointment with your plastic surgeon and discussed this with him. He will most likely have some specific recommendations to correct this issue.

The lower pole of my breasts have an indent. Have I Bottomed out? What is the next step? (photos)

Answers (8)

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