Breast Aug with Failed Revision- Why does this keep happening? What options do I have? (photos)

Last year I had a breast augment that resulted in slight bottoming out. 304cc silicone submuscular. I had a revision (capsulorraphy) 3/3/16 and am noticing the same signs of bottoming out. I am wondering why this keeps happening? Is it because I did light upper body workouts (no chest) after 6 weeks? Is it weak tissue? What are my options to keep my implants up like they were at 4 weeks post revision? I don't like my areolas so high on the breast with such a bottom heavy look. Please advise.

Doctor Answers 6

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.


Louisville Plastic Surgeon
4.7 out of 5 stars 44 reviews

Breast Aug with Failed Revision- Why does this keep happening?

I am sorry to hear about/see the problems you are having after revisionary breast augmentation surgery. I think your concerns are appropriate; your breast implants do seem to sit quite low on your chest wall, consistent with breast implant displacement ("bottoming out”).
 
I think you will benefit from revisionary breast surgery which will likely involve capsulorraphy ( internal suture repair). This procedure serves to reconstruct the lower poles of the breasts and prevent migration of the breast implants too far inferiorly. Associated issues with positioning of nipple/areola complexes should improve with this operation. Whether or not to use your existing breast implants will be very simply determined; if they achieve your desired outcome in regards to breast size/shape, then more than likely you can utilize the same implants. If not, the use of the appropriate size/profile of breast implants will not be necessary to achieve your desired outcome. In my practice, this is best determined using intraoperative sizers during surgery after careful communication with the patient prior to surgery.
Make sure that the plastic surgeon who does this procedure for you can demonstrate significant experience with revisionary breast surgery.
I hope this, and the attached link (dedicated to corrective surgery for bottoming out concerns), helps.

Redo breasts augmentation

Dear Luna,
  Thanks for submitting your before and after pictures and sorry for your problem.
  From observing your pictures, it appears that your surgeons used the infra mammary incision for entry . This entry incision , makes it very difficult to correct well and consistently the excessively low sub mammary crease. 
 I have been in practice for 29 years, and based on my experience with many situation like your, In my opinion,  the sub areola incision is much better approach to perform inferior capsulorrhaphy (internal bra ). That is because the procedure can be done under direct vision !
 Additionally, not all results are the same, because experience and skills are critical for good outcome.
 Another possible reason for the bottoming out is superior pole capsule contracture , that is pushing the implants downward. In that case, superior capsulotomy ( scar release ) is indicated, in order to prevent recurrence. 
  Medial capsulotomy will be needed too,  for giving you a much nice cleavage, which, again, can be done easier through sub areola incision.
   Always, consult with experienced board certified plastic surgeons who do lots of redo breasts augmentation in accredited  surgery center for your safety. Most importantly, check the before and after pictures in the photo gallery, to make sure that they are numerous, consistent and attractive.
                        Best of luck,
                                          Dr Widder

Bottoming Out / Internal Bra Repair

Good evening!

You do have a significant amount of bottoming out, and when patients come to me after a failed repair it is usually lack of experience that caused the problem- not using the correct sutures, not using enough of them, not placing them in the correct tissue layers- or some combination of those problems. 

The correct repair is the Internal Bra, my strong permanent internal suturing technique which corrects your bottoming out. This is the most common type of revision I perform, 5-6 times a week- it works and it lasts!

I have attached a link to my Internal Bra / Breast Augmentation Revision photo gallery for your review- hope it helps!

Revision surgery

It would be nice to know what type of capsule repair was performed.  Often suturing the capsule inferiorly helps and I like to use a thong bra. Sometimes strattice can help reinforce the repair.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Breast augmentation Bottoming out

LunaMarie,

Thanks for your question and for the photos.  Sorry your revision surgery failed.  You need an internal permanent suturing of the inframammary crease.  This should support the breast implant and restrict the downward progression.

Best of luck.

Dr. T

Douglas Taranow, DO, FACOS
New York Plastic Surgeon
4.8 out of 5 stars 51 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.