Can Bottoming out Repair Be Done Six Months After Implant Surgery?

Question

How often do patients need more than one surgery to repair when one nipple points up and isn't as full on top as it is on the bottom? How common is bottoming out after breast implants?

Richard H. Tholen, MD, FACS · Answer

One of your breast implants has dropped and the other remains in a better-appearing position. At 6 months your tissues have healed (nearly completely) and your internal and visible scars have likely faded and softened as well. Wearing a bra or elastic bandeau will not have a beneficial effect on CHANGING implant position, but may help to MAINTAIN position from further dropping.

	Depending on the technique and practices of your surgeon, you can either have a thin, soft, pliable capsule around your implants, or perhaps a thicker, more firm, and less stretchy capsule. The former occurs with careful, precise surgery and control of capillary bleeding, and avoidance of bacterial contamination and resultant biofilm induction at the time of pocket creation, as well as maintaining post-operative limitation of activities that could cause bleeding and a thicker capsule.

	A thick, firm capsule that does not stretch or soften over time occurs when the surgeon uses blunt dissection technique, surgical drains (rather than control of bleeding and bruising), and when he or she is, shall we say, less fastidious about bacterial contamination (implants out on the Mayo stand, sitting on cotton surgical towels, being touched by the surgeon's gloved hands--that touched the patient's skin, and being inserted through the incision dragging skin bacteria along with the implant; all leading to biofilm formation and higher rates of capsular contracture).

	You may know the cause based on the degree of bruising, swelling, and pain after your surgery, but it is clear that what happened on one breast did NOT happen on the other, and there could be any number of potential causes, some of which can be attributed to the surgeon, some to the patient, and some to random chance.

	At this point in time, the correction involves creation of a tighter and higher capsule on the side where the implant "bottomed out." This can usually be corrected with sutures alone, but some degree of over-correction is likely necessary, as well as wearing of continuous bra support for a minimum of 6 weeks after surgery. This operation may need to be repeated, but this is very unusual. Implant crease raising occurs in less than 3-4% of my breast augmentation cases, but I believe implants ALL drop to some degree in most all patients, so I "build in" a certain degree of over-correction initially. This reduces the number of re-operations for bottoming out, and if the implants don't drop quite as much as necessary for the best-looking result, it is a much easier (and successful) re-operation to DROP the implant pocket a bit, rather than raise the pocket and hope it stays there despite gravity, implant weight, and external bra support (and I tend to have patients who like large implants).

	You probably do not need Strattice or other ACDs, and these are expensive and don't always last long-term anyway, so I would defer this decision to your operating surgeon, who knows the condition of your tissues. I rarely need it, and even more rarely use it. For an example of a patient with "bottoming out" on one side after vertical lift (elsewhere), click on the link below. Good luck and best wishes!

Gary M. Horndeski, MD · Answer

Yes, 'bottoming out' can be repaired. It is a challenging procedure, but can be done using permanent sutures. It's not a common problem, but it can happen. In my experience this procedure does not need to be repeated if the patient adheres to my recommendations. I usually request the use of an under wire bra for at least 2 months to insure that the repair heals in place. I also recommend that ample support is always used after that.

	Best wishes,

	Dr. H

Jonathan Saunders, MD · Answer

secondary surgery occurs about ten % of the time after breast augmentation. 6 months is an adequate time to wait. i would like to see preop and post op pictures before making any further comments . your result may be related to how your breasts initially looked good luck

Armando Soto, MD, FACS · Answer

Hi there-

	I'm sorry to hear that your breast implant outcome is not as ideal as you would have liked..

	By 6 months after surgery, the structure and strength of the capsule your body formed around the implant should be adequate to support a long term repair of the shape of the pocket. There would not (in most cases) be any benefit to waiting longer.

	Different surgeons will vary in their preferred technique for the repair, but provided your surgeon is experienced in management of implant problems, you should be able to achieve a pleasing and symmetric outcome.

David A. Bottger, MD · Answer

Bottoming out which describes excessive descent of a breast implant resulting in a seemingly high nipple position, loss of fullness in the upper breast , and a drop of the lower breast fold position, is not uncommon. After six months a revisional procedure can be considered. In most cases only one procedure is necessary to fix the problem, but it is always possible that a revision may be necessary in the case of a over or under correction.

Steven Wallach, MD · Answer

Certainly by 6 months a revision can usually be done to treat bottoming out.  Usually this only takes on surgery, but in some cases may require additional surgery.

Tom J. Pousti, MD · Answer

Bottoming out can happen after breast augmentation surgery. I would suggest correcting it with capsulorrhaphy (internal sutures for better pocket placement) to assist with better placement of the implant on your chest wall. Not every surgeon has experience with this technique – experience is VERY IMPORTANT in this case. I usually ask patients to wait closer to 8-12 months post op to have the internal sutures performed. I have found that the closer the patient is to 1 year post op, the more successful the repair will be. Seek advice from a board certified plastic surgeon who has experience with this type of surgery.

Suresh Koneru, MD · Answer

6 months after surgery is usually a good time to wait before attempting a repair for this problem.  Usually by this time the capsule is formed well enough to hold stitches for a repair.

Steven Svehlak, MD · Answer

Hi, Malpositioning of a breast implant is one of the more common reasons for breast re-operation.  This can occur because of poor tissue quality that lacks support, a heavy implant, excessive muscle activity, and over dissection of the pocket during the initial operation. 

	This can be repaired with another surgery by 6 months, and sometimes sooner in some patients.  It is always better to wait longer before repairing this problem to allow full healing.  Success of this repair is based on the internal tissue quality of the breast and breast capsule.  If the tissues are firm enough, then usually internal stitching and repositioning in one procedure will fix the problem.  However, sometimes tissue quality is poor with very poor tissue strength.  Stitches will not hold up well in this circumstance and malpositioning may recur.  Other tissues may be needed internally, such as treated dermis, to help strengthen the pocket in order to improve support for and position to the implant.

Kamran Khoobehi, MD · Answer

You can have revision surgery if that is what you need. The rate of breast implant surgery revision is around 15-20%.The most common reason for the revoision is the implant size. For transaxillary augmentation the revision rate higher and implant position is the most common problem.

Can Bottoming out Repair Be Done Six Months After Implant Surgery?

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