Is this the start of bottoming out 3 months post op? Under muscle placement, 440cc Motiva progressive gel plus (Photo)

I am 3 months post op my breasts are still pretty wide apart my nipples are riding so high and are really full on lowerpole i cant cover in a bra , if bottoming out would i need a smaller size implant

Doctor Answers 10

Bottoming out?

Not all incisions are placed directly at the fold and many are often above the fold. From your frontal view the implants do not look like they bottomed out.  Best to evaluate in person.


New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Bottoming out

Large Implants due to their weight, gravity, thinning of tissues, chronically not wearing a bra, loss of elasticity and other factors may cause continued stretching so that your breast implant is no longer supported in its ideal position. This results in the progressive lowering of the inferior breast crease (inframammary fold). When the implant moves South to an undesired inferior position it results in the loss of volume and flattening of the upper pole of the breast, too much volume at the lower pole, increasing the distance from the fold to the nipple and finally the nipple position being abnormally high ( pointing up) and not centered. Similarly, the pocket can also stretch to the side (lateral) so that when lying down your implants fall towards your arm pits or sides, causing the “Side Boobs” appearance.
Bottoming out and Side Boobs Contributing Factors:
  1. Larger/Heavier Implants
  2. Implants placed above the pectoralis muscle
  3. Chronically not wearing a bra when upright
  4. Over dissection of the Implant Pocket
  5. Smooth Implants
  6. Large swings of weight including pregnancy
  7. Skin and soft tissue laxity, loss of elasticity

Bottoming out

Yes, your implants are bottoming out. This is why your nipples appear too high. The only solution at three months out to perform a revision surgery where the lower portion, where the fold used to be, gets stitched back down to reinforce and lift the implants. Then, an under wire or support bra while it is healing. Discuss this further with your surgeon, or with a second opinion.
Best of luck!
Dr. Subbio
Board-Certified Plastic Surgeon
Newtown Square/Philadelphia, PA

Christian Subbio, MD
Philadelphia Plastic Surgeon
5.0 out of 5 stars 52 reviews

Bottoming out

When a breast implant migrates below the original placement location with the bottom of the implant just above the infra-mammary crease, we call this “bottoming out.” There are several causes of this downward migration of the breast implant. Usually, some attempt had been made to lower the crease to accommodate a breast implant whose base diameter is larger than would otherwise fit in the natural breast. If not done correctly, the anatomic attachment of the skin of the breast to the chest wall can be obliterated. There is then nothing to hold the implant up. With the weight of the implant, and constant gravity, maybe lack of support by lack of wearing a bra continuously, the implant can settle downward. One of the earliest symptoms, in my patients, has been the feeling that the breast has to be constantly adjusted or just feels heavy. We look for the incision line, which was previously placed at the crease, to have migrated upward onto the breast. When we see this early on in the postoperative phase, it will never get better with time and will require a secondary repair. While some plastic surgeons may rely on suturing techniques only, I have found that unless we un-weight the implant by making it smaller or strengthen the tissues below by making them less stretchy, that the same implant, with just sutures placed on the bottom of the pocket, will, over time, recur it's bottomed out position. I have used part of the capsule as well as the lining of the deep muscles and tissues over the ribs in the capsule beneath the breast implants to rotate upward to hold the breast implant in a higher position and therefore obliterating the extra space that has been created between the correct infra-mammary crease and the one created by the downward displacement of the implant. I call this a three flap technique, as the skin, the capsule and fascia (lining of muscles), as well as a dermal flap all contribute to creating a hammock like support of the lower portion of the pocket. When these tissues are insufficient to hold the implant up, or a previous attempt has been made with sutures, I will oftentimes rely on the addition of another type of tissue called an acellular dermal matrix of which my preference is Strattice. This Strattice ,or pigskin, does not stretch and can be sewn in to the bottom of the new location of the crease to support it just like a hammock would. Although this is costly, I consider this an insurance policy against having to redo this again. I would recommend that you try and find a plastic surgeon with experience in revisionary cosmetic breast surgery. Good luck.

Marc J. Salzman, MD, FACS
Louisville Plastic Surgeon
4.7 out of 5 stars 44 reviews

Is this the start of bottoming out 3 months post op?

Yes, you are bottoming out. No, this is not because you have too-large implants, it is because your surgeon made the pockets too low, or did not factor in the effects of healing, softening, and stretch under the ever-present physical fact of gravity.

I see this problem all-too-frequently when my colleagues place a woman's implants in the "perfect" position in the operating room, even confirmed by upright positioning on the operating table, and then hope to negate the effects of gravity with an Ace bandage, elastic bandeau, or supportive surgical bra. Look in any nursing home to see how trying to outwit gravity works out!

Sometimes surgeons who DO take into the accounts of gravity by placing the implants a bit higher than their final desired position will STILL have bottoming out occur. At least we tried, and next time we get a bit better at trying to determine just how much to try to counteract gravity, healing, and stretch/settling over time. After a few years and thousands of implants some of us actually get pretty good at this.

But bottoming out still occurs occasionally despite everyone's best efforts.

When it does, blaming the implant is not the proper "solution," IMHO. Just repair the capsule, over-correct it a bit to allow for gravity and healing a second time, and have your patient wear a supportive bra to help the healing day and night for at least 3 months (longer is better). Successful repair is not guaranteed, but switching to smaller implants simply shifts the "blame." Not necessary, and frankly (since you would have to go down a substantial amount to make a difference), simply trading one problem (bottoming out) for another (too small implants, too-wide cleavage, and less upper pole fullness) makes no sense to me.

Just my two cents' worth! Best wishes! Dr. Tholen

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
4.9 out of 5 stars 239 reviews

Is this the start of bottoming out.

If the implant is moving lower and the point of projection is now below the nipple, yes, the implant is bottoming out. We suggest a firm under-wire to support the breast and do let your surgeon have a look to help out.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.1 out of 5 stars 40 reviews

Bottoming out

from your photos it appears that your right implant is lower and causing your nipple to sit higher. You would need to have the lower pole to be repaired to raise the inframammary fold to match the other side.

Deborah Sillins, MD
Cincinnati Plastic Surgeon
5.0 out of 5 stars 10 reviews

BA

You do appear to be bottoming out a bit.  In general, only a procedure to tighten your lower pole would be indicated.  However, a smaller implant would put less tension on the repair and would likely entail less of a risk of this occuring in the future. 

Is this the start of bottoming out 3 months post op? Under muscle placement, 440cc Motiva progressive gel plus

Thank you for sharing your question and photograph. I can see your area of concern and though nothing replaces an in-person examination it appears that your implants may be settling too low on your chest causing your nipples to become elevated.  Treatment would involve revision surgery to tighten the lower portion of the implant pocket and possibly a reduction in the size of your implant to avoid recurrence.  Voice your concerns to your surgeon, they can offer the best advice.  

Nelson Castillo, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 43 reviews

Bottoming Out?

Hello,

Thank you for the question and photos. Yes, it does appear that your implants are sitting slightly too low- especially on your left. I recommend that you be seen by your Plastic Surgeon in person for examination and discussion of options.

All the best

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.