One Breast is Smaller Than Other, Incision is Not in the Crease, and Doctor Says the Implants Are Sliding Down? (photo)

I had my b/a 6 months ago. Before getting it I had one breast bigger than the other. My doctor said he would fix this but I still fint my breasts uneven. He says I need a revision. He says its not his fault and that due to my age or my size,my body couldnt take the implants which caused the breast implants to slide down. He says this is the reason why the incision is not properly placed below the crease. I need advice. Is is possible for implants to slide out of place? Is this dangerous?

Doctor Answers 12

Breast implant malposition

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You have malposition of your implants inferiorly- they do not center your breasts.  Unfortunately you do need a revision on both sides.  Unfortunately, I do feel you and your surgeon choose implants that were likely too big for your body.  I recommend a review of your surgeon's revision policy.  If you choose an experienced board certified plastic surgeon I am sure he or she has a policy in place for situations like yours.  The problem is not serious but will not improve without surgery.  Best wishes!!

Breast Augmentation Revision

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     the breast augmentation can be revised by capsulorrhaphy with or without a change in the size of the implants.

When your nipples point upwards

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your implants are 'sliding' downward and bottoming out.  This is not dangerous but is affecting your appearances.  Wearing a supportive bra is important to help slow this process down but you are looking at some kind of operation if you wish to restore things to where they should be.  As for fault, implant malposition is a known risk of augmentation so I look at this as 'no fault'.  Talk to your surgeon and find out what his/her plan is to fix this and consider a second opinion if you remain concerned.  It is fixable but it will take a lot of your participation post-operatively to make it work.  Good luck!

One Breast is Smaller Than Other, Incision is Not in the Crease, and Doctor Says the Implants Are Sliding Down?

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You have "bottoming out"! Best to obtain ONLY INPERSON opinions from this point. Oveer the internet very hard to be accurate. Best of luck. 

Solutions for implant bottoming out problem

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You definitely have some bottoming out of your implants.  This can be due to several different factors including too wide of an implant, low placement of the initial incision and the use of high profile implants.   The problem with high profile implants is that these implants create a heavy central load, almost forcing the implants down.  It is important to place the incision in the proper position, use an implant of the correct base diameter to match your anatomy and I like to place fold sutures a the base of the pocket to establish and maintain the infrmammary crease and to keep the implant from drifting down.  Despite all of these efforts bottoming out can still occur.  To correct this problem a relatively minor inferior capsulopexy can be performed and placement of fold sutures.  This should even your inframammary creases, correct your nipple asymmetry and create better superior pole fullness.  Depending upon your pre-operative anatomy and size of implants used it may be beneficial to go to a smaller implant size.  

Your body "couldn't take the implants" is your surgeon's explanation??? And "not his fault!?"

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Although all of the answers thus far are correct in their assessment that you have bottomed out and require re-operation, I agree most with Dr. Schulman--this is caused by your surgeon's (perhaps honest and unintentional) creation of your pocket too low for "final" implant position. Large(r) implants can be a partial contributing factor in "bottoming out," but experienced breast surgeons also know to take this into account when creating the pockets for any or large implants.

Your surgeon being so defensive actually makes me believe he may in fact have intentionally created pocket positions that made you look great initially, but failed to take into account implants dropping over time.

Some surgeons use blunt dissection, are not overly concerned about hemostasis, and may have relatively high capsular contracture rates. Implant capsules that are hard and firm keep position, but even a less fastidious surgeon will have some patients who do not develop thick, firm, restraining capsules, and the implants drop over time. That your surgeon seems to imply this is "your fault" may also mean he doesn't really do many breast augmentations, or this would clearly become a recurrent problem that shows an observant plastic surgeon that his pocket position creation is the problem, not your age, body, or ability to "take implants." COME ON! is right!

These are not tissue transplants that your body can "reject." They are [inert] breast implants, and once a surgeon performs over a hundred augmentations per year for a few years, you begin to see that with carefully-performed, meticulous-technique augmentations, virtually every patient's implants drop over time--some more than others, and some taking longer than others, but (except when capsular contracture occurs) pretty much EVERY patient will have this happen. Observant and careful surgeons learn to expect this and make the appropriate surgical adjustments to accommodate this!

Taking this into account is the excellent surgeon's job, and accepting that we don't always get it exactly right is also our responsibility. That's part of being imperfect, but being defensive and "blaming" the patient is wrong on so many levels I won't discuss.

Your incisions also seem a bit low to start with (based only on your photographs). But implant position dropping changes the mound-incision relationship. Your incisions are not rising; your implants are dropping (as I anticipate for nearly every patient). When they are repositioned to their proper locations, I hope your incisions are not on your chest wall below the breast mound, but I fear they may be. This is another reason I suspect your surgeon may be so defensive and accusatory of you. If this is an honest error of judgement by an experienced ABPS-certified plastic surgeon who does lots of breast surgery, then why the blaming and defensiveness? Is this a common occurrence in your surgeon's practice?

EVERY plastic surgeon has patients whose implants "bottom out." The best plastic surgeons are the ones who do lots of breast augmentations, have figured this out, and have it happen very infrequently. We also have revisionary surgery policies in place so every patient knows what is expected if they are the (rare) patient this happens to.

If it happens too often by a particular surgeon, s/he may be going for the "marketing" aspect of having their breast augmentation patients look wonderful right after surgery, when they are excited and show all their friends, who come to that doctor for his "fabulous" early results. But when the implants drop (and they ALL do, eventually), then 6 months later these friends end up sitting in the doctor's lobby upset that they need re-operation for bottoming out that should have been anticipated and avoided by slightly higher implant placement initially! BTW, going with smaller implants at your re-operation may actually increase the likelihood of scar on chest wall malposition due to smaller implants having smaller base diameters! If your capsule is thin, you may require acellular dermal matrices to reinforce the inferior pocket tightening.

Unfortunately, this requires re-operation to "fix," but bottoming out is not dangerous. Wear a supportive bra and go see your surgeon. If he is not an ABPS-certified plastic surgeon, find one or more who you can consult with about this issue. Trust me, we've all seen it. Sorry it happened to you. Best wishes! Dr. Tholen

Bottoming out of implants

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Yes, your implants have bottomed out.  You will need resuspension of the fold and probably a smaller implant to correct this problem.

Bottoming out of implants

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Your implants have bottomed out. They are falling below the breast crease. I am sure your surgeon truly believes that this is not his fault, but the truth is that bottoming out of implants is an error ont he part of the surgeon and should never be blamed on you or your body type. "Your body couldn't take the implants"? Come on. There are 2 reasons why this happened. Either the implants that you selected were too big for you (which your surgeon should have known ahead of time and recommended a smaller volume), or he/she disrupted the breast crease during the surgery.  You will need a revision. This revision will require reconstruction of the breast fold (maybe with the use of acellular dermal matrix such as alloderm or strattice), and likely exchange to a smaller implant. You may want to consider a second opinion from a board certified plastic surgeon experienced with implant revisions. I am sorry this has happened to you.

Correcting "Bottoming Out" after Breast Augmentation?

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 I'm sorry to hear/see the complication you have experienced after breast augmentation surgery. Your breast implants have “bottomed out”;  this is  one of the many ways breast implants can displace after breast augmentation surgery. The situation is not dangerous but may cause problems wearing certain clothing… You may find that the nipple/areola complexes being off centered on the breast mounds,  may also be problematic when wearing bras or swimming suits. Occasionally, breast implant displacement issues can also cause discomfort in the areas where the breast implants are applying pressure to the underlying skin.

 I also agree that revisionary breast surgery is indicated. Correction will involve internal suture repair of the lower poles of the breasts ( capsulorrhaphy).  This procedure will serve to keep the breast implants higher on the chest wall.  This repositioning of the breast implants will allow for the nipple/areola complexes to be better centered.

Make sure that, whoever you decide to have correct this problem,  can demonstrate significant experience  with this type of surgery.

 Best wishes; hopefully you will be pleased with the long-term outcome of the breast procedures.

You may also find the attached link helpful to you.

Bottoming out

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Bottoming out is not rare, it is not dangerous, it is not anyone's fault. It occurs when the implant descends below the original breast fold. It is more likely with larger implants and with smaller breasts with high breast folds. Without pre-op photos it is hard to guess if these were factors or not for you. If you place your finger on the incision and press straight back to the ribs, this should approximate the look you should expect with surgery to correct this. 

You should discuss carefully with your surgeon the pre-op planning and the post-op care needed to minimize the chance of recurrence.

Thanks for your question, best wishes.

Jourdan Gottlieb, MD
Seattle Plastic Surgeon

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.