Does a Caspuslorrhaphy Involve Stiching to the Ribs?

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?

Doctor Answers 8

Capsulorrhaphy for breast implant malposition

Thank you for the question and pictures.

One of the most common complications after breast augmentation surgery is implant mal-position. This occurs when the implant is in an incorrect position on the chest wall. This may include incorrect position of the implant superiorly (“riding high”), inferiorly (“bottoming out”), medially (“symmastia or uni-boob”) or laterally (falling outward into the axilla).

In your case, I would suggest repair of the  inferior breast capsule with permanent internal sutures (capsulorrhaphy). This involves removal of a segment of breast implant capsule among the inferior/lower aspect of the left breast implant pocket. The 2 edges of  capsule tissue are sutured to one another with permanent suture. This procedure reduces the size of the implant pocket and prevents the descent  of the implant on the left side.  Suturing to the ribs is not necessary and  complication prone. This procedure will improve the symmetry of the breasts  and the positioning of the nipple–areola on the left breast mound.

Make sure you're working with a well trained experienced board-certified plastic surgeon.  Capsulorrhaphy, even in the best of times, is not always successful and further revisionary surgery  including the use of allograft ( I use this material for cases of recurrent implant  malposition)  may be necessary.

 I hope this helps.


San Diego Plastic Surgeon
5.0 out of 5 stars 1,499 reviews

Capsulorrhaphy after breast augmentation

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.

Laurence Weider, MD
Dallas Plastic Surgeon
5.0 out of 5 stars 99 reviews

Does a Caspuslorrhaphy Involve Stiching to the Ribs?

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. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.6 out of 5 stars 174 reviews

Capsulorraphy can resolve implant bottoming out

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:

  1. Calculate the appropriate size of implant for the pocket and verify that it is not too large
  2. Open and widen the upper aspect of the pocket to free the implant to move up
  3. Weaken the pressure by the Pectoralis muscle
  4. 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).

Mario Diana, MD
Plano Plastic Surgeon
4.5 out of 5 stars 28 reviews

Repair for a low breast implant

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,


Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 43 reviews

Pocket Options Include...

You definitely have bottoming out. Options to fix include ( in the order that I would perform them)

1. Tighten the lower pocket - the inferior capsulorrhaphy. This basically closes the lower pocket and raises the implant. Success rate is dependent on internal tissue, size of the implants and how much the tissue stretches.

2. Use of Alloderm or Strattice. This uses dermal tissue (from a cadaver or pig) to reinforce the position of the fold and helps keep bottoming out from recurring. The issues are cost of the material and placement of artificial material.

3. The last option would be to advance the skin and create a new fold with your own tissue. I would use this only in a reconstruction or severe malposition.

Good Luck!

Brian Klink, MD
Vacaville Plastic Surgeon
5.0 out of 5 stars 94 reviews

You will need to have pocket revision

Your condition is due to detachment of the infra-mammary ligaments from the chest wall. This is due to the surgical dissection. The use of the AlloDerm is indicated in the cases that the normal tissue is missing. You need to find a surgeon that has experience with pocket revision . This is seen more in the trans-axillary breast augmentation due to the lack of visualization.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.7 out of 5 stars 124 reviews

About Breast Implants Bottoming Out

"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.

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 110 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.