Which BA technique to avoid bottoming out? (Photo)

Question

Dear Doctors, I want to get a BA soon and I was wondering if there is a technique that is the safest against bottoming out, my biggest fear. I have minimal tissue (bra size 34AA) and my pocket width has been measured as 9.5cm by a surgeon and 11cm by another (which I found odd). That leads me to pick UTM, high profile gel implants. Preferred range 290 to 340cc and I'll let the doc decide. I hear great things about dual plane technique, is that good to avoid bottoming out in the future?

Finny George, MD · Answer

Hi, thank you for sharing your question. There may be some ways to reduce the risk of bottoming out but it may not be avoidable in some cases. Implant selection, pocket dissection, and use of mesh are all factors that can affect long term outcomes.

Daniel Barrett, MD · Answer

Dear MartiCo,
bottoming out occurs when the implant falls below the current breast crease or inframammary line. It's more likely to happen with inframammary incisions, which is why I try not to use the inframammary approach to any breast surgery.
Bottoming out can also occur if an implant is too large for the breast pocket. That is why it is important to choose an implant size that's correct for your body. I perform numerous measurements in the office to determine optimal implant size for my patient's bodies.
If you are concerned, please check it with your plastic surgeon for reassurance and to further discuss your options and possibility of revision.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Jeffrey M. Darrow, MD · Answer

The best way to avoid bottoming out is to choose an implant that fits within the normal boundries of your breasts and preserves your natural inframammary fold.  The inframammary folds strength prevents inferior migration of an implant, so choosing an implant which would require lowering the fold and creation of a new fold using sutures, to accommodate a larger implant is possible, but the re-created fold is never as strong as the native fold.  Other options for creating a fold below your native fold would be the use of a reinforcing material such as Galaflex, which is a mesh sutured in at the level of the new fold and incorporates into your bodies tissues, but creates a stronger lower fold than could be obtained with sutures alone, although at an increase cost.  Dual plane pockets, simply referred to the different amounts the pectoral muscle is divided and separated from the breast tissue to achieve optimal shape in a breast augmentation.  Best wishes.

Matthew C. Camp, MD · Answer

Independent of plane of placement, steering clear of very large implants will serve you well in avoiding bottoming out. Large implants stretch the skin, and sit lower than desired. Dual plane is upper pole of the implant under muscle, and the lower pole under skin and fat. Under muscle placement helps disguise implant rippling, which is not a huge issue due to the cohesive nature of gummy bear implants. Due to your small frame, a 250 cc range implant will likely look amazing, and not over-stretch the skin.

Gerald Minniti, MD, FACS · Answer

There are people who are more prone to bottoming out than others, and you may be one of them. Don't get me wrong, if done appropriately, your risk will be no greater than anyone else. But, if a surgeon only measures breast base width, ignores nipple to fold distance on stretch, and picks a ultra high profile device that's still too large, you'll drop out and have double bubble. An examination would confirm, but your breast tissues appear tight, and the distance from nipple to fold short. For a device whose volume is 300 cc, you'll need 8 cm on stretch; if you don't have that, then that 340 will lift your native inframammary fold off of your chest and the implant will descend. As for discrepancies in measurements between different surgeons, all I can say is that measuring breast dimensions is dependent on the person whose measuring them, so pick an expert. Part of the surgical 'technique' is pre-surgical implant selection, which is where a lot of operations go wrong.

Ronald J. Edelson, MD · Answer

Since your skin is tight and the lower portion of your breast is not stretched out you are at little risk of bottoming out regardless of the technique used. As long as you don’t go with very large implants and the size range you describe shouid work fine

Gary M. Horndeski, MD · Answer

No breast augmentation technique avoids bottoming out. The force of gravity will always push the implants down. When implants are placed under the muscle or partially under the muscle, the muscle contracts and also extrudes the implant inferiorly and laterally. The best way to minimize inferior and lateral displacement of the implants is to place small implants. At size 34, each 100 cc of implant corresponds to 1 cup size change. 300 cc implants will take you up 3 cup sizes.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Ram Kalus, MD, FACS · Answer

Thanks for your question and photo. There is no guaranteed way to prevent bottoming out, regardless of technique, but there are definitely measures that can be taken to prevent this or reduce the likelihood. A board certified plastic surgeon can review with you all of your options.

In my own practice my preferred pocket placement is subfascial, thus avoiding the constant downward forces on the implant (other than gravity) of the pectoral muscle contractions over the implant.

It is critical to avoid too large or heavy an implant, which also ensures the likelihood of a more natural result. Please consult with a board certified plastic surgeon with whom you feel confident and comfortable, and whose results resonate with your wishes. Best of luck to you.

Alper Burak Uslu, MD, FEBOPRAS · Answer

Hi dear Martico, bottoming is the coined term to describe the look where the upper pole of the breast is deflated whereas all the volume is gathered on the lower part. It's mainly due to native breast tissue descent and encountered after breast reductions or lifts mainly. Because the amount of tissue that you have is minimal the risk of bottoming out is almost negligible. I think what you are afraid is the inferior migration of the implant. Main factor for that would be surface of the implant (textured implant tend to migrate less) and insertion plane (submuscular or dual plane insertions are known to be more stable for the implant), lastly reconstruction of the imf at the end of the procedure. Because you have a tight skin envelope the risks are also minimal in your case.

Camille Cash, MD · Answer

Implant selection is important to keep your risk of bottoming out low.  Very large implants are too heavy for the tissues and can lead at times to bottoming out.  Your choice to have the implants placed under the muscle will be helpful as the muscle will provide some support for the implant.  We welcome you to visit us in our Houston office to learn more!

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