Left breast bottomed out. Which procedure is best for revision? Sutures only or sutures with ADM? (photo)

375 silicone unders done about 18 mos ago. Bottoming out of right breast started to be noticeable at about 3 mos post op. I don't mind the look of either breast, just want symmetry! Both doctors (original surgeon and second opinion) said it was fairly "mild" bottoming out and questioned whether or not I really want another surgery. I trust both surgeons, but I don't know who is giving me the best recommendation? I am very thin with very little natural breast tissue. Thank you.

Doctor Answers 10

When capsulorrhaphy alone doesn't work for bottoming out

Implants bottom out because of lack of support, which means the tissue is too weak. Since you are thin and know that there is little tissue coverage, you are less likely to have a successful outcome with capsulorrhaphy alone. It doesn't matter what type of suture or technique is used because it is the tissue that has to support the implant. That doesn't mean that capsulorrhaphy will not work, but I would consider using ADM such as Strattice or a mesh such as Galaflex or SERI.


Seattle Plastic Surgeon
4.9 out of 5 stars 48 reviews

Bottoming out

I agree with Dr. Revis's answer below. I perform capsulorrhaphy on a regular basis and rarely need  the addition of a biologic or synthetic mesh for support. Your problem is fairly straight forward and should have an excellent outcome. Make sure your surgeon has extensive experience with capsulorrhaphy.

Paul E. Chasan, MD
Del Mar Plastic Surgeon
5.0 out of 5 stars 33 reviews

Bottoming Out / Internal Bra Repair

Good evening!
I perform a lot of Internal Bra repairs for Bottoming Out- about 5-6 per week, and most do not require an ADM. I usually reserve it for those patients who have had a failed repair before I met them, or for those with extremely thin tissues. Since it is expensive, I would rather examine you before making you commit to the ADM. The ADM is not without its own set of complications as well, so if you can have a successful repair without it that is best. 
I have attached a link to my Breast Augmentation Revision / Internal Bra photo gallery for your review- hope it helps!

When one is lower than the other

you have to choose which one you like better and either lower the higher one or elevate the lower one with elevation being much harder to do and less predictable.  I personally will avoid ADM if at all possible and will not use it on the first go around.  If the revision failed, then ADM would be discussed.  When implants are elevated, my patients have to wear cut out bras 24/7 to help support the incision line for 6-8 weeks.  And if you have a contracture, that must be addressed as well.

Curtis Wong, MD
Redding Plastic Surgeon
4.8 out of 5 stars 32 reviews

Implant is a bit bottomed out... What now?

Great question, 3 possibilities:1. Capsulorrhaphy to raise implant. My best one is with cautery in the segment to eradicate it, slight over correction, use long term but not permanent suture (like PDS)2. Back up plan, if I get in there and you have a paper thin see through capsule I can see right through... ADM from muscle to proper location of crease. Again mild over correction as adm stretches by about 20%3. Crazy idea, lower your right side a bit to match. Really depends here on your preferred aesthetic. Advantage of that is that it's a two minute surgery and I would try to talk your original surgeon into it. ;)

Lisa Cassileth, MD, FACS
Beverly Hills Plastic Surgeon
4.7 out of 5 stars 13 reviews

Breast Asymmetry

Hello,I agree with you, and would not want my patient to look like this. I think absorbable meshes have overtaken ADM's as a support structure; they are thinner, porous, don't require drains, and much cheaper. Although suture techniques could probably do the job well, using a mesh is extra insurance. An ABPS certified/ASAPS member surgeon who is a revision breast specialist would not hesitate to help you.Best of luck! 

Gerald Minniti, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 79 reviews

Treatment for bottoming out with breast implants.

We are each guided by personal experience and I have consistently had success with capsulorrhaphy without the use of ADM.  Either approach is a good one however so other than a significant increase in expense you might consider either procedure based on your trust in your surgeon.  If a capsulorrhaphy were to fail, you would then need to consider ADM but I have yet to see that happen.Regards and good luck.Jon A Perlman MD FACS  Certified, American Board of Plastic Surgery  Extreme Makeover Surgeon ABC TV Best of Los Angeles Award 2015, 2016  Beverly Hills, Ca 

Jon A. Perlman, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 30 reviews

Different approaches

Thanks for the great question and the photo. Having an implant bottom out can be super frustrating for both you and the surgeon. Implant malposition (off to the side, too far to the middle, or bottomed out) can be tricky to fix. There are a multiple ways of fixing it, both with pros and cons. Using ADM will increase the cost of the surgery but will likely give additional support in the long run that sutures won't be able to. Choosing between using only sutures vs ADM is multifactorial and has to do with the size of your implants and the quality of your skin and soft tissue. It never hurts to get a third opinion from someone who specializes in revision breast surgery to see what they think. It's difficult to give my opinion without seeing you in person. I hope this helps and best of luck!~Dr. Sieber

Breast revision

I want you to be very careful about your next surgery, as you are entering into the breast revision stage, which for everyone should be done one time, but frequently several surgeries are done.  So, do your due diligence and pick a great surgeon who you like and trust - preferably your first surgeon.  I just hate it when folks get into a vicious cycle of needing revisions.  Since your IMF is now obliterated and your implant has bottomed out, you need that anatomic structure repaired and often reinforced, as you mentioned.  A capsule revision (capsulorrhaphy) would be needed, although even this on its own can sometimes break down, especially with big heavy implants.  If I'm concerned, I will often use ADM, especially one that doesn't get more lax over time (e.g. Strattice) and place this at the IMF to act as a sling, and this should hold it in place hopefully forever.  Good luck!

Left breast bottomed out. Which procedure is best for revision?

I am sorry to hear about/see the problems you are having after breast augmentation surgery. I think your concerns are appropriate;  the left breast implant does seem to sit quite low on your chest wall, consistent with breast implant displacement ("bottoming out”). As you mentioned, this breast implant displacement does cause significant breast asymmetry.

It is possible that you are feeling the implants significantly along the lower poles of the breasts.  Also, consistent with the breast implant positioning problem, the nipple areola complex seems to be sitting relatively high, because the breast implant have settled too low. 

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. 

In my practice, this type of repair involves a two layer, permanent suture repair (reconstructing the inframammary fold areas). Sometimes, depending on the clinical situation and history, the use of additional support materials such as acellular dermal matrix or biosynthetic mesh is also helpful.

 I would suggest that you communicate your concerns again directly with your plastic surgeon. Working together you arrive at the best plan (for example to operate on one or both breasts) to achieve an outcome that you will be happier with. Make sure that he/she has significant experience with this type of revisionary breast surgery;  experience does matter with these types of operations.

I hope this, and the attached link (dedicated to corrective surgery for bottoming out concerns), helps.

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.