How Does a Plastic Surgeon Create a Pocket That Will Not Allow Bottoming Out?

How does a plastic surgeon ensure that a relatively large silicone implant (400-450cc) will not bottom-out if only minimally covered (top 1/3-1/2) by pec muscle? What prevents the inframammary fold from slipping down below the pre-surgical level?

Doctor Answers 13

Bottoming out of breast implants

I was interested to read the other plastic surgeons opinions on this one. The definition of bottoming out is not well defined and can relate to double-bubble deformity but there are at least two types of bottoming out. There is also a long list of "causes" of bottoming out which even a cursory evaluation reveals that there is no consistency in patients or even from one side to the other. 

The two types of true bottoming out are a stretch of the lower pole (half) of the breast with the implant ending up too low relative to the nipple but the inframammary crease is still in the correct position. The other and more common type of bottoming is when the inframammary crease stretches and lowers relative to the correct position for it which results in the implant being too low. If the incision to put the implant in was made in or near the inframammary crease, it will appear to rise up on the underside of the breast. There is a third type of pseudo-bottoming where the non-bottomed side has an implant that is too high which makes the other side look too low. 

Here is a partial list of reasons given for bottoming out that in my opinion and experience are not consistent or are insufficient to explain it. It can also happen on one side and not the other when the two sides were ostensibly done the same. 

-- too big an implant

-- under the pectoralis muscle (some think it pushes the implant down, some think it helps support it)

-- moving the inframammary crease

-- bra (wearing it, not wearing it, wearing it too much or too little)

-- patient anatomy or cause (side of arm dominance for example)

Tissue behavior can't be completely controlled, particularly over time, but the other factors can be known and controlled for. In my experience and opinion, a breast implant has to be properly sized to fit behind the breast properly and must be positioned properly at surgery and then healed in that correct position. If the inframammary crease is too tight or short it must be lowered to accommodate a round implant that is sized to the width of the breast. If this is done then the crease level must be re-secured to the chest wall and healed there. Implants that are too big in the sense of being too wide for the pocket behind the breast want to move or stretch and can end up in the wrong position but it's not because the implant is too many cc's of volume. I don't think the pectoralis muscle causes or prevents bottoming whether it's released in a dual-plane type release or not. Violating the fascia below the edge of the pectoralis is necessary for certain breast shapes and sizes but could only result in forward type of bottoming if the inframammary crease is reestablished. 

Correction of the stretched or lowered inframammary crease type of bottoming can be corrected without the use of allografts. The inframammary crease level has to be reconstructed or restored via an inframammary crease incision (if this wasn't already present) but it doesn't require grafting donor tissue. 

The bottom line, as it were, is that even doing everything correctly, there are still cases where bottoming can occur and often it is not possible to be sure what caused it and how to avoid it every time. Fortunately it can be avoided most of the time and can be corrected if it occurs. 

Boulder Plastic Surgeon
4.0 out of 5 stars 1 review

Implants falling below the IMF are ALWAYS due to poor planning or execution.

Hi there-

This is honestly not a problem adequately trained and experienced plastic surgeons should experience.

The inframammary fold is an anatomic structure, that when appropriately respected, will NOT, somehow stretch or weaken spontaneously. 

In some patients, reconstruction of the fold is necessary, and a good outcome in these circumstances would require this (experience and recognition of these patients is very important).

I guess I would say the take home message is to choose your surgeon very carefully, and your risk of this complication (as well as others) will be low.

Armando Soto, MD, FACS
Orlando Plastic Surgeon
4.8 out of 5 stars 159 reviews

Breast Augmentation Technique to Prevent Breast Implant Bottoming-out

There are multiple factors that come into play when discussing the possibilty of implant descent and malposition. They include implant size, surgical technique and inherent quality of the patients skin and breast tissue. Too big of an implant and laxity in the tissues combined with an already long nipple to fold distance can lead to bottoming out. The attachments of the inframammary fold have varaible strength as well, just as the chest skin does which are the primary support for the implant. Technique which violates the IMF and weakens the support tissue can also lead to this deformity. Implant choice as well as a possible textured implant may help prevent descent as well.

I hope this helps.

Andrew P. Trussler, MD
Austin Plastic Surgeon
4.9 out of 5 stars 46 reviews

Breast implants properly placed should not bottom out

When a breast implant after breast augmentation sags below the nipple it is said to have bottomed out. This is not something that naturally occurs, even with a large breast implant. The breast pocket, in both under the muscle, and in over the muscle augmentation must center the implant under the nipple and exactly fit the implant hand in glove to keep it correctly positioned. If breast augmentation is well done, bottoming out is so infrequent that we don't find it an 'issue' in our practice. Even the most experienced surgeon can see a positioning problem, though the good news is that a low or bottomed out implant can be corrected,  its just not high on the worry list.

Best of luck.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 43 reviews

Bottoming out after breast implants prevented with good technique.


1)  Everybody gets an occasional complication in plastic surgery, including bottoming out.

2)  But there is no magic.  Bottoming out can be prevented by really studying the patient's anatomy, by having a good individual surgical plan, and by making the breast implant pockets meticulously.

3)  Just before the end of surgery, when doing breast augmentation in Manhattan, we put the patient in the sitting position (of course, you are still asleep) and we check to make sure the folds under the breasts are exactly where they should be.  Potential bottoming out can usually be predicted.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon
4.8 out of 5 stars 9 reviews

Preventing Bottoming Out with Large implants

Is skin was a great building material we would NOT have stretch marks, jowls, facial sagging, droopy butts, pot bellies and sagging breasts. You get the idea. Skin gives and ages. So in principle you cannot count on skin to provide a permanent support for any significant weight. In other words, in the battle between gravity and skin - skin ALWAYS losses.

The keys to avoiding a bottoming out are:
- precise pocket dissection. Not undermining more than in needed inferiorly to relocate the inframammary fold to the ideal location
- use the smallest implant you can live with. All implants will sag with time (just as all breasts in 50 year old women sag in comparison to 20 year olds) and implants over 350cc sag faster
- if possible place implants through an around the areola approach. Going through the breast fold will weaken the fold. (Some surgeons may differ with this. But- in my opinion and that of others this is more than logical).
- pick the right Plastic surgeon.

Good Luck.

Dr. P. Aldea

Peter A. Aldea, MD
Memphis Plastic Surgeon
4.9 out of 5 stars 109 reviews

How Does a Plastic Surgeon Create a Pocket That Will Not Allow Bottoming Out?

Excellent question: sometimes it is unavoidable. Precise pocket dissection respecting the anatomic boundaries is probably the most important factor that the surgeon can control. Beyond this appropriate implant size is an issue. Textured surface implants may remain more fixed in their positions. Use of acellular dermis or crease fixation sutures in reconstuctive cases is another technique.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 82 reviews

Several factors contribute to bottoming out with breast implants

Surgical technique is part of the answer, but as you have pointed out the muscle covers the top of the implant and does not add support from below. A hyperactive pectoral muscle can actually push the implant down over time and cause bottoming out. One of the biggest contributing factors is implants that are too large, which will succumb to gravity over time regardless of how precisely the pocket is created. There are a few specific things that can be done, such as using the fascia from the rectus muscle in the lower portion of the pocket. To correct bottoming out, a Strattice graft can be very useful.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 53 reviews

Preventing bottoming out after breast lift

preventing bottoming out begins with good surgical planning and technique. The implants should be placed under the muscle .A sling of acellular dermis(Strattice) in combination with breast parenchymal flaps should be considered as well.Good bra support is imperative. Naturally ,larger implants require more internal and external support than smaller implants.

Burr von Maur, MD
Orange County Plastic Surgeon
4.6 out of 5 stars 22 reviews

Bottoming Out with Implants

The goal with preventing bottoming out is to not violate the inframammary fold any more than necessary.  The fold is a strong connection between the skin and the underlying tissues.  If possible, the goal is to leave this intact.  There are some women on whom you need to lower the fold to accomodate the implant, or correct some abnormal anatomy of the breast. 

In these patients, you need to be careful with the dissection and not disrupt any more of the tissues than necessary.  Once the implant is in place, the closure needs to include a deep closure of the tissue that incorporates those tissues at the bottom, so that the implant sits exactly where you place it.  Even then, you can get bottoming-out, but it is rare.  In reality, the rate should be 1% of women or less.  I hope this helps.

Christopher V. Pelletiere, MD
Barrington Plastic Surgeon
4.8 out of 5 stars 75 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.