What strategies do you as surgeons use to avoid bottoming out of implants?

Bottoming out refers to stretching of the lower pole breast skin/tissue increasing the nipple to IMF distance.  In my opinion, the transaxillary approach where the breast crease is lowered can weaken the inframammary breast crease and contribute to this problem.  Overly large implants will place more stress on the lower pole and also contribute to bottoming out.  Finally, a patient tissue quality/elasticity is important in maintaining.  In cases where my patient may have poor skin quality I generally will place internal suture to support the inframammary breast crease.  In addition, the inframammary breast crease approach and choosing an appropriate but more conservative implant size will decrease bottoming out.

Hello and thank you for your question and sharing your photos. Successful outcomes after breast augmentation needs careful surgical planning, implant selection, meticulous surgical technique, and good post op care. I would avoid using excessively large implants as they tend to stretch out skin envelope and cause bottoming out. I would seek consultation with a board-certified plastic surgeon
for a full evaluation and advice. Best,
Pejman Aflaki, M.D.                                            
Johns
Hopkins-trained double board-certified plastic surgeon

Surgical expertise and good judgment are the most important factors.   You cannot change your intrinsic tissue quality.  Surgical technique for breast augmentation should allow for conservative muscle release but preservation of all retaining fibers inferior to that. Your PS should help you decide on an implant size to prevent it from being too big and heavy for your skin and breast tissue.  The dissection of the pocket for the beast implant must fit appropriately and implants should be placed in the dual plane.

Hello Jubilant2138,


I favor Dual-Plane
over Partial Submuscular (under the muscle) breast augmentation,
because Dual-Plane placement allows for a more natural appearance
while keeping the benefits of having the muscle cover the implant. On the other hand, under the muscle implant placement is typically more
painful, have a significant risk of bottoming out of the breast, and it’s associated with a longer period of recovery,
and more post-operative discomfort. Bottoming out
is a complication that occurs when the implant rides too low in the
breast tissue, causing the nipple to point upwards. Correction for bottoming out
involves breast augmentation revision surgery that recreates
the pockets within the breast that holds the implants. Patients with
poor skin elasticity are most at risk for this problem, which is often
accompanied by rippling. Placement of excessively large implants also
significantly increases the risk of bottoming
out.
I would recommend consulting with a board-certified and experienced plastic surgeon to assess your candidacy for breast augmentation and discuss your specific concerns. With appreciation, Dr. De La Cruz.

Thank you for sharing your question.  Using precise surgical technique and a well-sized implant relative to a patient's natural anatomy helps to limit the risk of bottoming out.  Hope this helps.

That’s a great question… In almost all women, the inframammary fold sits a little too high for most implants to provide a balanced breast (45% of the implant/volume above the nipple and 55% below)  and an almost all cases surgeons need to adjust that information refilled. My feeling and experience is anything that weakens that area too much could allow the implant to slip too low. Here is where I disagree with Dr. Burns. Having done the axillary approach for over 20 years now, I believe it has LESS of a tendency because there is no incision in the inframammary fold. The dermal fascial attachments are not weakened by the incision and the dissection, and I think it provides more support. therefore I think the axillary approach or periareolar has the lower chance of bottoming out but honestly, it all comes down to surgeon experience. Great results can be obtained with any incision!! I also think it helps if patients can get into a snug underwire bra once their implants settle where they like them. It may help to wear that for the first 6 to 8 weeks or so just to “lock them in place“. My favorite is the Victoria’s Secret Knockout bra

The best thing to avoid bottoming out is to evaluate the strength of the patient's skin (presence of stretch marks, thickness, etc), avoid large and heavy implants, place them in a position to add some muscle support, etc, assess the amount of the skin and native breast prior to surgery etc. These and many other variables that board certified plastic surgeons learn throughout their training, need to be taken into account to avoid bottoming out. There are some technical aspects that are dependent on the surgeon's preferences.Best of luck and be safe!

There are 2 major reasons for bottoming out of implants.  One is they are too heavy for the skin envelope to hold.  An implant of 450 cc weighs 1 lb and the weight of the implant exceeds the mechanical strength of the skin.  This frequently results in descent down the chest wall.  This can be avoided by using smaller implants.  The other cause is women who have nipple-areola complex that has migrated down the chest wall.  These women frequently need a lift but choose or are directed to augmentation alone.  If this is done then the implants have to be centered underneath the nipple-areola complex, which requires lowering the inframammary fold.  Once the inframammary fold is lowered it gives less support for the breast and the implant will migrate inferiorly and laterally.  Unfortunately, you have not provided photographs or told us your bra size.  However, you may or may not be at a high risk for these complications.Best Wishes,Gary Horndeski, M.D.

Bottoming out relates to the ability of the breast tissue and skin integrity to resist the gravitational forces of the implant pushing downward, which is inevitable, especially in women with an active lifestyle that may include jogging, dancing, aerobics, etc. One of the keys is to avoid too large an implant. the heavier the implant, the greater the risk of bottoming out. That said, a common misunderstanding is that the sub pectoral or dual plane approach helps prevent this. The reason this is not the case is that the muscle coverage is actually on the upper 1/2 or 1/3 of the implant, not the lower. There are several surgical maneuvers that can be performed, but in a patient who is suspected to have particularly loose tissues, there are additional materials that can be used by your plastic surgeon to support the implant on its lowest portion and can act like a hammock. Please consult with an experienced board certified plastic surgeon who can best address all of your concerns after evaluating you in person. Best of luck to you. 

Hello and thank you for your question.  The best advice you can receive is from an in-person consultation.  Bottoming out should be avoided in every patient.  In order to minimize this risk, I recommend not attempting to lower the inframammary fold during surgery and not over dissecting the inferior border of the pectoralis muscle.   Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.  

Best wishes and good luck.


Richard G. Reish, M.D.  FACS

Harvard-trained plastic surgeon