How Best to Revise Implants That Have Bottomed Out?

I had saline implants placed above the muscle approximately 12 years ago. I now wish to have a revision surgery performed. I would like to eliminate the rippling that is currently occurring with the saline implants I have. What is the best implant for a natural, full look with minimal rippling? I really want to avoid the "bowling ball" look and would like a very natural appearance. What are the arguments for going above vs. below the muscle? Could my muscle have atrophied over time?

Doctor Answers 11

Bottoming out of saline filled implants

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All saline filled implants can get rippling along the edges. Soft tissue coverage is the key. As long as there is sufficient soft tissue to cover the edges of the implant you will be fine. Otherwise I would consider a gel implant. The long term fate of a saline filled implant is to round out the bottom of the breast as the implant is heavier than a gel.

Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Using a breast revision technique for breast implant bottoming out

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The rippling and bottoming out of an implant can be improved with a capsulorraphy and implant exchange.  The overall look of your breasts will be improved. 

Raffy Karamanoukian, MD, FACS
Los Angeles Plastic Surgeon
4.8 out of 5 stars 95 reviews

Bottoming out repair

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I like to wait  at least 6 months prior to correction of inferior displacement of breast implants (bottoming out). This allows for the capsule tissue around the breast implant to have increased strength and hold sutures better (capsuloraphy)- I think this allows for improved chances of successful repair. Allograft reconstruction may also be helpful, especially if the implant malposition problem is recurrent.

In regards to implant pocket change, I think that exchanging the implants to the submuscular position at this time carries increased risks of complications.


Make sure you seek consultation with a board-certified plastic surgeon with significant experience with revisionary surgery. Best wishes.

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PHOTO: Bottoming out Saline breast implant augmentation

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This seems to be well covered here but I wold recommend transition to a moderate plus silicone gel filled prosthesis with inferior capsulorraphy and prolonged wearing of a padded underwire bra for 6 weeks to support the repair

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

Rippling and bottoming out

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To correct the bottoming out, the folds can be reinforced and a capsulorrhaphy can be performed. As for rippling, it is tough because it relates to the soft tissue coverage.  Silicone gel impalnts tend to ripple less, and if need be  alloderm can be used to help.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Breast implant rippling and bottoming out

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To correct the "bottoming out," my general approach is to re-establish a higher inframammary fold by careful lateral and inferior capsulorrhapy with Ryan type sutures placed under general anesthesia.  This mandates removal of your current implants, surgical reconstruction of the implant pocket margins, and replacement of the implant.  

Regarding the causes and treatment of visible rippling, understand that currently available implants in the United States may all ripple to a degree.  Form stable implants awaiting FDA approval will not be prone to rippling.  Strategies for minimizing visible rippling include gel implants instead of saline, if saline is used perhaps slight overfilling, submuscular or dual plane implant placement, smooth surface implants, and smaller implants.  The higher the percentage of your final breast volume that is implant, the more your breast will behave like an implant, and that includes implant texture, and rippling.  If you are very lean, count on at least some palpable (although not necessarily visible) rippling, especially at lower outer edge.  Another possible strategy if you have the time, money, and risk tolerance is implant removal, fat grafting of the breast, and subsequent implant placement. 

Steve Laverson, MD
San Diego Plastic Surgeon
4.9 out of 5 stars 50 reviews

Bottoming out of breast implants.

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I recommend not going any larger than you already are and even consider going a little smaller.  Switching to a gel implant in the submuscular position is likely to address the rippling problem.  Your surgeon will need to carefully close off the lower part of your existing pocket to keep the bottom of the implant higher than where it is now.  I do this with closely spaced permanent sutures and require my patients to wear and underwire bra for two weeks, 24/7 to help this area seal off and prevent recurrent bottoming out.  Also, some surgeons are using dermis such as Alloderm or Stattise to help with rippling or recurrent bottoming out.  This material is very expensive and probably best reserved for really tough, recurrent cases.   

Lisa Lynn Sowder, M.D.

Lisa Lynn Sowder, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 77 reviews

Bottoming out

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This is a difficult dilemma.  As implants have existed for many years, we are seeing this problem more commonly.  Additionally, it is now the standard to place implants submuscularly.  It was more common to place implants subglandularly in the past.  In short, the more tissue that exists between the implant and the outside world , the better.  Ideally, the implants should be removed.  You may need a partial or complete capsulectomy (this involved excising scar tissue from around the implant).  A silicone implant is often a good option due to less rippling.  Then, either your own capsular tissue or a dermal matrix may be required to tether the implant behind the muscle and to stop it from returning to the subglandular plane.  When seeking the appropriate physician, please ensure that they have performed this case often.  It is not a simple fix. Good luck!

Jason Hess, MD
San Diego Plastic Surgeon

Breast Implants Bottoming Out

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Time, large implants or over aggressive dissection can lead to bottoming out of breast implants. Saline implants are the most common cause of rippling and this is made worse when placed above the muscle.  The solution for you would be related to changing out your implants to silicone with the size to be determined, using some of the existing capsule around your current implant to support the new implant and placing the new implant beneath the muscle.  These operations are complicated so it is important to find someone who is skilled in revisionary breast surgery.

Best of luck,

Vincent Marin, MD, FACS

La Jolla Plastic Surgeon

Vincent P. Marin, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 52 reviews

Silicone gel implant will help but not 100%

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The main issue that you complain  is the rippling and also the bottoming out. The rippling can be corrected to some degree with silicone gel implants. You will need to have pocket revision to help with the bottoming out. The idea of the exchanging the pocket from sub glandular to sub muscular sounds good but can be challenging due to the muscle scarring from the implant.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.7 out of 5 stars 153 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.