I had my surgery on June 24, 2011. What Are my Options to Correct Double Bubble?

Question

I had my surgery on June 24, 2011. I was a 34A and got 520cc silicone implants. However, at the 3 month mark I started to notice something was off. The incision was under the fold and my surgeon promised that it would not be noticeable, and that this was the only way to fit such a large silicone implant along with lowering my crease, so i trusted him. I now have double bubble and my breast stay raised up in the air, always exposing my incisions. Its been 18 months. What are my options?

Vishnu Rumalla, MD · Answer

Thank you for your question. You indeed have a double bubble deformity with bottoming out. You had very large implants placed and besides the suture repairs and possibly Strattice placed like other surgeons reccomended, I think you do need to seriously discuss reducing the size of your implants with your surgeon as part of the potential treatment plan. Good luck.

John J. Corey, MD · Answer

I usually try to fix this first by fixating sutures at the bottom and then have patients avoid bouncing or pressure for 6 weeks and wear an underwire bra non-stop. If this does not work I may then go to Strattice, but because of the cost of the product I usually don't go to that as my first choice unless the patient is willing to use it...

Steven Goldman, MD · Answer

Your photographs show both a double-bubble deformity and bottoming out. The breast implants appear to have migrated below the original inframammary folds, recruiting abdominal skin onto the breasts and becoming visible below the breasts. In general, repair would involve an inferior capsulorraphy (sutures placed at the bottom of the scar tissue envelope that forms around the breast implants) to raise the pockets. The so-called acellular dermal matrices (like Strattice and Alloderm) are sterilized dermis (skin) from various sources. They may be used in cases such as yours, but I generally feel that they are only needed in more severe cases than yours.

	Of course, to determine the specific surgical plan and possible outcomes, you must have a formal consultation with a board certified plastic surgeon familiar with breast revision surgery. Thanks for your question.

Steve Laverson, MD, FACS · Answer

Your breast width was much wider than distance between nipple and inframammary crease before surgery. Because the implants are round (most of them), your surgeon needed to lower the inframammary crease, OR accept an artificially wide intermammary distance. When the crease is lowered, there can be a visible junction between native breast tissue superficial to the implant and the subcutaneous implant just above the new inframammary fold. To avoid this problem, we sometimes radially score the underside of mammary parenchyma facilitating redistribution of breast gland over the implant, but this technique has its limitations, and probably increases the incidence of capsular contracture by entering breast ducts that are colonized with commensal bacteria. If you have round implants, consider replacement with Biodimensional elliptical implants (e.g. Allergan Style 410 low height full projection) or even Style 363 Saline. At the time of your procedure, the lower pole should again be radially scored, and capsulorrhaphy performed along the inframammary crease as well. Don't be upset at your surgeon. He or she did the best possible job considering your pre-surgical presentation and the implants available.

Ramin Behmand, MD, FACS · Answer

Your identification of the problem is correct, in that you do have a moderate double bubble deformity. This issue aside, you do have a nice result from the breast augmentation surgery. Therefore, treatment should focus on what is good and correcting the lower poles. There are two reasonable options here: one would be to reinsert the correct position of the inframammary fold with sutures into a higher position and the second would be to remove a crescent of inframammary fold skin while reinserting the position of the fold to a higher point. In your case, the first option is more desirable. The timing is also good now that you have a well formed/healed breast capsule, allowing for placement of stronger sutures to repair the position. Option two is less likely to have problems and more certain to be successful in most hands, but there is te associated longer inframammary scar. As for your current scar, it is still immature and the color will most likely fade more as it matures. I hope this helps. Ramin Behmand

Antonio Gayoso, MD · Answer

Your photos do seem to indicate that you have developed a double bubble and bottoming out after large volume breast augmentation. I do feel that this can be corrected surgically, either with the use of an acellular dermal matrix product (Strattice, Flex HD, Alloderm) or without. Both scenarios involve a return to the operating room and supporting stitches in the inframammary region in order to correct the bottoming out and reverse the double bubble changes. The use of the acellular dermal matrix provides a bit of an insurance plan that the corrections can be made and long lasting, but it is not imperative that you use ADM. Downsizing your implant is a consideration that might also assist in long lasting correction of this problem.

Steven Wallach, MD · Answer

The fold can be raised back up, you may want to consider smaller implants. Some would consider using Strattice for additional support but it is fairly expensive.

Robert L. Kraft, MD, FACS · Answer

I agree that you have a double bubble effect.  Going from an A cup to your current size is more likely to produce this, in my experience, than a more modest augmentation.  The scar itself could be treated to be less noticeable. The left breast is slightly larger than the right and demonstrates the condition with more significance.  Certainly you could have a revision with tightening of the breast pocket, or you could choose to do nothing.  Secondary surgery always has its own complications so it is a question of what you are most comfortable living with.

Ralph R. Garramone, MD · Answer

Judging by the photos you do seem to have a "double bubble" which appears to be more noticeable on the left side of the image compared to the other side. This problem involves descent of the breast implant below the original inframammary fold leading to a second bulge under the breast.

	There are a number of reasons for this.  It has made the scar more noticable. Typically this is treated by raising the fold usually with internal stitches. This type of repair needs to be diligently supported with a bra after surgery since the weight of the implant rests directly on this repair beginning immediately after the procedure.

	I would consult with your original plastic surgeon and with perhaps two others to get their opinions for correcting this and also get information from them about their experience dealing with this particular problem.

	Thank you for your question and for the photos and good luck.

Tom J. Pousti, MD · Answer

Thank you for the question and picture.

	I think you are correct,  in that your breast implants have displaced inferiorly ( bottomed out).

	Bottoming out involves inferior migration of the implants. This causes the nipple areola complex to appear too high on the breasts. Also, the distance from the areola to the inframammary fold is too great. This is corrected by &ldquo;raising&rdquo; the inframammary fold using internal sutures. This is done after careful measurements are made from the areola to the &ldquo;new&rdquo; inframammary fold.

	Correction of the bottoming out may help &ldquo;hide&rdquo; the existing inframammary incisions as well.

	I would suggest in person consultation with plastic surgeons who can demonstrate significant experience with this type of surgery.

	Best wishes.

I had my surgery on June 24, 2011. What Are my Options to Correct Double Bubble?

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