What Kind of Revision Do I Need for Bottoming out and Rippling After Augmentation and Lift 1 Yr Ago?

I am 49,5'9",128lbs,breastfed 7 children-34B prebaby, 36D-DD pregnancy/nursing, 34A post.I had BA/donut lift,subfasical,340cc textured silicone(34D)then experienced rippling by 3 months postop. At 7 months post, PS moved implants to dual plane with vertical lift. They looked good but by 3 months post, they began rippling and by 5 months bottoming out. It is 1 yr post - rippling bad and no upper pole fullness, but no contracture. I have little breast tissue or chest fat. Suggestions?

Doctor Answers 11

Rippling even with Subpectoral Placement

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From your photos you seem to have very little fat on your body including your breasts. I assume these are saline implants. The third photo and fourth photo shows your current condition. i would like you to gain some weight and soft tissue coverage of your implants but that probably won't happen. The 'bottoming out" does not appear to be severe. The nipples have migrated north so I would remove skin with a horizontal excision at the crease level to level the nipple/areolar complex.This will also shift the implant to the upper pole and improve this area.  At the same time I would recommend replacement with Round Silicone Gel Implants. It may not totally correct the rippling but will result in a better appearance with less rippling.

Hope this helps!

Orlando Plastic Surgeon

Addressing Bottoming Out & Rippling

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"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. . Rippling of #saline implant is unlikely a serious issue. If you are very thin or lean, any type of #implant can display some #wrinkling.  However, #positioning under the muscle may help.  Silicone implants do better than saline in this case. Also, adding a mesh (i.e. #ADM or similar) can help. Smaller implants, skin #tightening and #capsulectomy may also treat  #rippling or #wrinkling.  It is best to consult with your Plastic Surgeon to better confirm with an in-person exam. 

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 116 reviews

Sientra smooth moderate plus profile implants are useful for rippling

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I am updating an old question (posed in 2011) with a new (2015) answer.  After performing over 2500 breast augmentations over 20 years, I can make the following suggestions:

  1. Change from saline (which I presume you have) to silicone gel.  Silicone gel implants ripple, but they ripple less than saline.
  2. Change from textured implants to smooth implants.  Smooth implants ripple, but they ripple less than textured implants.
  3. Consider Sientra smooth moderate plus profile silicone gel implants.  No, I don't own shares in the company.  I have found these implants, which were released in the U.S. late last year, to be very effective in reducing rippling, more so than Allergan or Mentor smooth round implants.  The Sientra are highly cohesive "gummy bear" implants, so they have relatively little rippling.
  4. Inferior capsulorrhaphy (internal sutures for tightening and lifting of the implants) will help reduce the bottoming out without the need for another lift.
  5. No matter how you treat this problem and no matter how good your surgeon, you will still never have a perfect result.  All we can reasonably expect is significant improvement. 

Ronald Friedman, MD
Plano Plastic Surgeon

What Kind of Revision Do I Need for Bottoming out and Rippling After Augmentation and Lift 1 Yr Ago?

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Textured gel implants may show more rippling in patients with thin tissue than smooth gel implants, so that might help.  Despite being subpectoral, your breasts are naturally low on your chest, so the pectoralis muscle is not giving you much additional tissue coverage farther down on the breast.  You do have some drop out, though not severe.  You may benefit from Strattice support to the lower breast to try to prevent recurrent drop out and add some additional thickness of tissue to camouflage the rippling, and changing from textured to smooth surface silicone gel implants. Ultimately, there are some patients with very thin tissue and larger skin envelopes that "need" implants to fill out the skin but who do not have enough tissue thickness to hide the edges and irregularities of even gel implants. Strattice, although expensive, may help these patients to some degree, but their results may never be perfect. 

Large breast implants not a good option for thin women

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Thin women with significant tissue loss from breast feeding, pregnancy or weight loss often desire a curvy shape.  However, there are some signficant drawbacks to exceeding the tissue "load" ability of the breast, one of them being even further thinning of what breast tissue is left.  Stretching and thinning will lead to severe rippling and bottoming out.  In these situations I recommend:

  1. Smaller silicone filled smooth walled implants:  sizing will depend on particular anatomy, but in general no larger than a final C cup
  2. Capsulorraphy, using self derived skin "bra" from skin reduction during the lift.

The critical element of a successfull revision in these situations is to not exceed the load capacity of the residual breast tissue and skin envelope, therefore it is necessary to reduce implant size.

Mario Diana, MD
Plano Plastic Surgeon

Bottoming out

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Your case is complicated and I agree that you have very little body fat.   It is difficult to say exactly without examining you, but probably I would suggest capsulorrhaphy (internal sutures for better pocket placement) to assist with the bottoming out as well as AlloGraft to assist with the rippling.  I would also change your saline implants for silicone gel.  Seek advice from a board certified plastic surgeon who has experience with this type of surgery.

What Kind of Revision Do I Need for Bottoming out and Rippling After Augmentation and Lift 1 Yr Ago?

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Thanks for posting your photos and history. You have a very difficult issue. There is no perfect answer. I might suggest a re lift with upper pole fat grafts (if you have any fat?). Other wise the Strattice is quite expensive for the very high possibility of a no result. I would try the re lift first, simple first. 

Sometimes a breast augmentation won't be a home run

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I have learned after 20+ years of doing this that some body types are especially hard to get a great breast augmentation and you are one of them.  Over 40, super thin with no breast tissue, you have almost no chance of not having implant problems especially the bigger you go.  Strattice may help but you will always have ripples and may ever get the result you want. 

Correction of bottoming out after breast augmentation

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There are a couple of options to help with your problem of bottoming-out and rippling. One option is to perform a capsulorraphy, where the pocket is expanded superiorly and closed off inferiorly. This can be accomplished with a running suture technique or with a cadaver graft. Using the suture technique seems to work extremely well without the added cost of the grafts. If you still have textured implants you might benefit by replacing them with a smooth walled implants that tend to ripple less.

Robert M. Jensen, MD
Medford Plastic Surgeon
4.8 out of 5 stars 46 reviews

Fat grafting and pocket revision and smaller implant may help

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Your breast tissue is very thin and going above the muscle make the situation worse. Your breast present a difficult situation. there is minimal soft tissue,loss of skin elasticity and implants bottoming out. I have revised patient in your situation with combination of fat grafting(you do not have much fat), pocket and mastopexy revision and going with smaller implants. You can check my web site for examples.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.7 out of 5 stars 152 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.