How Should I Proceed if the First Repair of Bottoming out Was Not Successful?

I am 5'7 & 140lbs after having lost about 125 lbs. I had a tummy tuck and a breast augmentation with silicone moderate profile (659cc) under muscle 7 mths ago. Two months later I began running with excellent bra per doctor's approval. I bottomed out. I had revision surgery almost 2 months ago. My capsule was reinforced with the muscle folded extra for added sucture strength. I have bottomed out again. What would you suggest? In addition to smaller implants, is a lift needed to reinforce it?

Doctor Answers 7

Correction of Bottoming Out?

Thank you for the question. 

it would be in your best interest to seek consultation with a board-certified plastic surgeon  well-versed in revision a breast surgery. Correction  may involve capsulorrhaphy and/or  use of acellular dermal  matrix.

Best wishes.

San Diego Plastic Surgeon
5.0 out of 5 stars 1,488 reviews

Correction Of Bottoming Out

As usual it would be easier to provide an answer to your question if you had included a photo.  Your primary problem as you somewhat alluded to is the fact that your implants are too large which greatly increases the chance for problems.  The other thing that you might consider would be the use of Stratice or another ACD, but that will add significantly to your cost.

John Whitt, MD (retired)
Louisville Plastic Surgeon
5.0 out of 5 stars 2 reviews

Bottoming out after breast augmentation

I generally repair the bottoming-out with suturing of the capsule first. To date I have seen no recurrences with the current technique I've used over the past several years.  Prior to adopting this current technique, I saw many recurrences in both my patients and other surgeons' patients with previous suture techniques. If bottoming out ever recurs after this first repair, I recommend proceeding with a Strattice repair.  I currently use this approach since I've seen no recurrences with the capsule repair technique, and the Strattice implant is so expensive.  Without the benefit of examining you and going only by your history of recurrence after one repair, I would most like recommend a second repair with Strattice to maximize the support of the implant and the tissues.

L. Dwight Baker, MD
Dothan Plastic Surgeon
4.6 out of 5 stars 35 reviews

Bottoming Out After Breast Augmentation

It is difficult to evaluate "bottoming out" without photos, but if it occurs soon after surgery it is generally because of one of two possibilities. Either your skin has poor elasticity or the implant is too big and heavy. In your case it is probably both reasons. Most massive weight loss (more than 100 lbs.) have had the skin, including the breast, stretched out and will not support a heavy implant. Also, a 650 cc. implant is going to be heavy for anyone. Strattice, in internal sheet of acellular dermis (skin) will help but you will need a much smaller breast implant and probably a breast lift to tighten up the loose skin.

Joseph Fata, MD
Indianapolis Plastic Surgeon
5.0 out of 5 stars 101 reviews

Bottoming out again--3rd operation pending.

Congratulations on your weight loss! The loss of elasticity that accompanies major weight loss (and aging) leaves skin that has less tensile strength, a higher likelihood of recurrent thinning and stretch, and (particularly with larger, heavier implants like yours) more potential for bottoming out. In many cases, "planning" for this and anticipating a certain degree of implants "dropping" into position can help to avoid or reduce this occurring, but in all honesty, I still have the occasional patient that drops even more than I anticipated or accommodated for, and surgical repair becomes necessary.

Unfortunately, there are surgeons who believe that proper implant position is something to be achieved immediately in the OR, and then a surgical bra or ace bandage is advised to try to "hold" the breasts in this appearance. Obviously, sometimes this works, especially if there is a tighter, thicker and more restrictive scar capsule around the implants.  But wait, aren't we as plastic surgeons trying to achieve a soft, thin, pliable capsule so the breasts are soft and natural, not like croquet balls in your vest pocket? So if your surgeon is a careful, meticulous technician and avoids bleeding and contamination in the creation of your pocket, you end up with a nice thin capsule scar around your implants that eventually softens, stretches, and your implants DROP! And now with repair, there is only a thin, wispy scar capsule to try to reinforce and sew together. Enter Strattice or other ADMs (acellular dermal matrices, including Alloderm, etc.) to help provide thickness, bulk, and reinforcement to the lower breast (a sort of sling of tissue).

ACDs are "all the rage" now, particularly in university hospital settings where many plastic surgeons on staff are salaried, and the very expensive ACDs are used for insurance-reimbursed cases. For cosmetic self-pay cases, the patient has to pay, but the doctor has come to rely on the use of these materials, so the cost of re-operation goes up, but does the success rate? To be fair, when absolutely necessary, ACDs are a godsend. But IMHO, they are overused (over-recommended) as a panacea for cases such as yours, particularly as a second re-do. They also tend to reabsorb eventually, and all that expensive help may end up relying on the "rest" of the surgical repair to keep things where you want them. 

I believe that proper pocket position (a bit high at first, allowing the inevitable dropping to occur) helps to reduce this complication in the first place. When it does occur and capsulorrhaphy (suturing the capsule into a different--higher, in this case--position) is needed, a certain degree of over-correction must again allow some degree of eventual dropping to be taken into account. This too has failed in your situation.

So at this point it is critical to understand how you have arrived at this point. Was your initial implant position "perfect" and you dropped too low over 5 months requiring raising of your pocket? Or did you start out high, and dropped too far? Did you wear a bra early on, or did your doctor have you wear a band to help drop implants and "over shot" your desired position? How did things look after your first revision? Were you (properly) over-corrected and over 2 months again dropped too low, or did your sutures "tear through?" Or was there not enough over-correction for what your tissues tell us to do?

As you can see, these are the questions your surgeon (or any other plastic surgeon who would take up your case) must first answer (correctly) before advising Plan C. Obviously, Plan A and Plan B did not yield the proper long-term result, so Plan C should really be carefully considered to minimize the likelihood of needing, god forbid, Plan D or E!

It might be easy to "blame" heavy or "too-large" implants, but within certain anatomic limitations you should be able to be any size you wish, so an automatic recommendation to decrease implant size (and make you pay for new implants again, especially if you really like your present size!) may be a partial cop-out or shifting of the proper surgical plan. Adding a lift may be part of the same train of thought. Still, to be fair and honest, if you do feel too big, and do wish for a higher, tighter, perkier look, then either a lift alone with the same implants, or a lift plus smaller implants can help to move you to a result both you and your surgeon can be proud of and happy with. All this (especially if Strattice is recommended as part of Plan C operation) comes at a $$ cost. This unfortunately often becomes the major determinant of surgeon recommendation, or patient choice, so here is where I would caution both surgical intellectual honesty in making the best recommendation for the highest chance of (this time) finally achieving success, and patient realization that cheapest often ends up costing much more in the long run (think Plan D and E operations, cost, time off work and productivity, not to mention becoming jaded or discouraged by the process). Don't "cheap out" and end up requiring another revision!

Which, BTW, is still always a possibility even when the surgeon does everything right and so do you! Neither patient nor surgeon has received their perfection badge in the mail yet! My mother says mine is coming, but I've been waiting a long time, and I have come to realize that my mother may just be more proud of me than I deserve!

For an example of a patient who underwent a journey similar to yours, click on the link below. Good luck and best wishes! Sorry for the long answer, but I felt this kind of question without more information or photos needed this to be truly helpful.

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
4.9 out of 5 stars 255 reviews

Strattice for repair of breast implants bottoming out

Breast implants can sag if there is inadequate support, which is called bottoming out or lower fold malposition. Strattice, a type of acellular dermal matrix, is sort of like an internal bra that adds support.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 52 reviews

Repeat bottoming out of breast implants

I would suggest you consult with a surgeon experienced in the use of Strattice to reinforce the pocket and hopefully resolve your problem.

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
4.8 out of 5 stars 67 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.