Does a Caspuslorrhaphy Involve Stiching to the Ribs?

Question

I have bottoming out on one of my implants. I have been on multiple consultations trying to find a surgeon to correct this. I am confused because I keep getting different opinions on what I need to do to fix it. I've been told about everything from creating a "hammock" out of cadaver skin to hold my implant up to some light "tuck stitching" to hold it up. One PS told me the only way it will hold for sure is if my skin is stitched and hooked permentently to my ribs. Is this true?

Laurence Weider, MD · Answer

As others have stated, you have experiences bottoming out on your right side. There are various ways to fix this. One of the more commonly used methods includes elevating the pocket by attaching the capsule to the rib periosteum (the outer lining of the rib). There are also products such as Strattice that have been used successfully to re-create a pocket in cases of bottoming out. Make sure you find a surgeon who has experience fixing this problem. Good luck.

Jed H. Horowitz, MD, FACS · Answer

"Bottoming Out" is the term given to implant #displacement, where the implant drops down below the existing inframammary fold; the natural crease beneath your breast. This may occur when the fold has been released excessively during surgery or may be due to factors of the patient’s collagen and tissue integrity. The implants then sit very low on the chest with a lack of internal support for the implant itself.Correction usually involves #restoring the crease beneath your breast to it's normal position with internal reconstruction of the capsule around the implant (#capsulorrhaphy). Sometimes a biologic fabric (Acellular Dermal Matrix or #ADM) can be used to attach to the breast tissue internally while supporting the implant.This corrects the placement of the implant, redefines the breast shape, and also refines the internal fold.
To manage scars following the procedure, I suggest #scar maturation products to my clients. Such as BioCorneum or Embrace, to name a few, are recommended. But, it's best you wait a few weeks following your surgery, to begin using them and speak to your surgeon about healing concerns.

Darryl J. Blinski, MD · Answer

Sorry for your issues. There are many opinions/options to try and correct the "bottoming out" issue. Recommendations might include acellular dermal matrixes with deep "rib" sutures. Best to continue to obtain in person opinions.

Mario Diana, MD · Answer

Bottoming out is defined as the middle of the implant being below the nipple/areola complex, with most of the implant below the middle of the breast. For a successful capsulorraphy, we recommend:

	
		Calculate the appropriate size of implant for the pocket and verify that it is not too large
	
		Open and widen the upper aspect of the pocket to free the implant to move up
	
		Weaken the pressure by the Pectoralis muscle
	
		Double running suture line folding the lower breast pocket on itself in a double or triple layer


	The vast majority of successful capsulorraphy at our center do not require the use of synthetic materials or suturing to the rib (very painful).

Peter E. Johnson, MD · Answer

When an implant pocket is low and the implant is projecting low below the nipple there are options, and solutions, though nothing always works so opinions vary. We favor suture repair of the pocket with a double row of sutures internally in the pocket alone, not the rib. This is called capsulorrhaphy and like a hernia repair for a very few the repair might not hold. The next option is adding support, one of the many 'allografts' to reinforce the lower support under the implant, and we would use this only if the first repair did not work.

	Best of luck,

	peterejohnsonmd

Does a Caspuslorrhaphy Involve Stiching to the Ribs?

Answers (8)