BA 3 years ago with 450cc cohesive silicone gel over the muscle with severe rippling, bottoming out and uneven nipples (Photo)

I noticed a severe amount of rippling that got worse, bottoming out and uneven nipples. I went back to my surgeon and she is willing to fix it. She mentioned a pocket exchange and placing it under muscle dual plane. Will the implant still bottom out? She also suggested using Allergan natrelle implants at a smaller volume of 435cc High profile. So the only two options for high prof is 435 and 500cc. I'm not happy about downsizing from 450cc. But there's also the option of Mod profile for 470cc

Doctor Answers 10

Breast augmentation revision

Dear Dn416,

Thank you for your clinical post and sorry to hear of the progression of your post-implantation aesthetic appearance. The one side of your breast augment has indeed bottomed out and being in the subglandular plane rippling is quite noticeable on the upper and upper medial pole. There is definitely pseudoglandular ptosis on that side and on the contralateral side there has been very little bottoming out with a nice chest-breast junctional take-off.

I thinking having another discussion with your surgeon and discussing maintaining this particular volume and changing profile or decreasing the implant slightly will have less significance than putting this implant in the submuscular plane and providing inframammary fixation. Inframammary fixation will help stabilize the lower pole using a low dual plane technique will likely minimize the risk of rippling post-operatively.

I think on the non-descended side you have a nice result. The left side has bottomed out. There is pseudoglandular ptosis with elevation of the nipple areolar complex. All of these should be greatly improved with enhancement revision surgery and I think you’ll end up with a nice result.

Keep in close communication with your operating surgeon and best of luck

R. Stephen Mulholland, M.D.
Certified Plastic Surgeon
Yorkville, Toronto

Toronto Plastic Surgeon
4.7 out of 5 stars 80 reviews

Rippling and bottoming out 3 years after subglandular cohesive gel

Placing the implant underneath the muscle in a dual plane approach will correct the rippling.  The bottoming out can also be corrected by changing the pocket.  The proposed implant size change is modest, and is much less important than correcting the implant position.  I think that a carefully formed new pocket can correct the issues without the need for acellular dermal matrix. 

Implant issue

If you have a lot of rippling, then you likely need a pocket position change to under the muscle and probably would benefit from an ADM to camouflage the implant and thicken the soft tissue coverage.

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

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BA 3 years ago with 450cc cohesive silicone gel over the muscle with severe rippling, bottoming out and uneven nipples

You have two issues that in my opinion are more important than implant size. The first is pocket stretching. Changing to a subpectoral pocket is definitely a good option, but I would recommend reinforcing the pocket with a mesh sling like SERI mesh to help prevent recurrent stretching which can occur even with a pocket site change (going from on top to under the muscle).
The second issue is the thinness of your tissue which contributed to the first problem and also is the reason for the wrinkling and palpability that you have now. Changing to a different volume implant and/or higher profile doesn't help very much with this issue. The options for improving this include using a gel implant with a higher viscosity (meaning a thicker gel) like the firmer gel used in the "gummy bear" or highly cohesive gel implants. These implants are stiffer feeling, but hold their shape and don't wrinkle as much. Your surgeon can also wrap the implant with an absorbable mesh or ADM product which your body reabsorbs over time as it lays down a layer of your own tissue in its place which thickens the tissue. The third option would be to do some fat grafting to your breast in the areas of the wrinkling. This may be best to do at a follow-up procedure once you have healed from the initial revision. Good luck.

Breast augmentation Revision

I agree with your surgeon's plan for pocket exchange. You will likely need a dermal sling to help keep the implant from bottoming out or moving into the other pocket. You can keep your implant the same size but you will be taking the risks of bottoming out (which is also causing the nipple position problems) and rippling - although these risks are decreased in the submuscular position. Best wishes!



Thank you for your question and photos.

I recommend that you focus more on the correction of the pocket/asymmetry than the size of implant. A range of 20-40 cc size difference is relatively small. Your Plastic Surgeon will be able to recommend on that they feel is the best fit, size & shape for you based on your measurements. A slightly firmer, high or full projection implant placed under the muscle could help reduce the appearance of rippling and capsulorraphy with strong reinforcement should address the bottoming out.

Seek a second opinion in person if you are uncomfortable with the plan.

All the best

Bottoming out breast implants

You will most likely need a revision of your breast implant to achieve a more aesthetic appearance.  This may include removal of the capsule and adjustment of the breast implant pocket.

Rippling and bottoming out after breast augmentation

Based only on your photos I would recommend changing to a subpectoral/ dual plane in order to conceal the upper portion of the implant.  I would also consider using acellular dermis or biologic mesh for support of the implants to correct bottoming out in addition to capsulorrhapy.  I would not increase the size of your implant and also consider a textured implant for added support.  

Raymond Jean, MD
Philadelphia Plastic Surgeon
5.0 out of 5 stars 20 reviews

Disappointment with results

I agree with conversion to submuscular/dual plane, pocket revision/capsulorraphy but would add possibility of biologic mesh for support depending upon quality of capsule. I don't necessarily think you need to downsize, in fact a slightly wider device would aid in adding superior pole fullness, and going from a 450 to 435 is a negligible difference of 1 tablespoon anyhow. I would encourage a high fill implant like Allergan Inspira SRF of 450 or even 485cc to gain some width and further reduce rippling. Seek multiple opinions from breast experts not just any plastic surgeon who dabbles in all aspects of plastic surgery. Best of luck. 


your nipples were asymmetric before guaranteed.  to satisfy my own curiousity why did you have them placed subglandularly to begin with?  what was the advantage?

Jonathan Saunders, MD
Newark Plastic Surgeon
4.7 out of 5 stars 59 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.