Solutions for poor skin elasticity post br aug, resulting in "bottomed out appearance" with rippling. Can this be corrected?

I am 6 months postop from re aug with 400cc silicone sub muscular and pocket revisin d/t bottoming out. My nipples are again high on chest wall yet incision scar remains close to ribs, indicating I did not bottom out again but my surgeon feels rather that my skin elasticity is poor and stretched giving a bottom out appearance with no fullness on the upper half of my breast. If revision with tightening of skin as suggested by surgeon is performed, is skin likely to continue to stretch? Solutions?

Doctor Answers 4

Bottomed out implant

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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 58 reviews

Bottoming out after BA

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Bottoming Out after Breast Augmentation Treatment
Although an exam would be required to offer a specific opinion in your case, it would appear the the main issue you face is bottoming out and not drooping (ptosis). Therefore the appropriate treatment would be to reconstruct you inframammary crease in its original position (for example using an internal Ryan procedure). That would not require a breast lift incision. Also helpful would be textured implants and placing them in a submuscular pocket to minimize re-bottoming out
Good luck

Skin issue

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It sounds like you need a lift of some sort, and yes the skin may stretch out due to poor quality.  Hard to say without an exam.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Solutions for poor skin elasticity post br aug, resulting in "bottomed out appearance"?

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I am sorry to hear about the problem you are experiencing after breast augmentation and revisionary surgery. Based on your description, it seems like you are experiencing a breast implant displacement problem.
Generally, the "bottoming out" breast implant displacement problem can be corrected using an internal suture technique (capsulorraphy) along with the use of acellular dermal matrix orbiosynthetic mesh.
My best suggestion: make sure that your selected plastic surgeon has a significant/demonstrable experience achieving the types of outcomes you will be pleased with.
I hope this, and the attached link (dedicated to "bottoming out" breast implant displacement concerns) helps. You will find a separate page, on the same website, dedicated to the use of acellular dermal matrix. Best wishes.

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.