How to fix bottoming out & improve cleavage (Photos)

Question

I have 425 high-profile implants. They bottomed out a few months post-op after having my creases lowered. Preop pics in profile. How can I resolve the bottoming out and also improve the cleavage? I have more side boob than cleavage.

Kenneth Hughes, MD · Answer

This will involve closing the pocket inferiorly and laterally to move the implant up and in.Kenneth Hughes, MDLos Angeles, CA

Aldo Guerra, MD · Answer

Your breast implants look too big for your breasts. Downsizing with a new pocket and textured breast implants will probably help a lot to get a better upper pole. Consider a true gummy bear - MemoryShape TM+ for better long-term stability.Good luck, Dr. ALDO

Farbod Esmailian, MD · Answer

Thank you for the photos.Fairly common issue for which patients present for breast revision surgery.  Lateral migration of the implant is another issue as well.  In most instances, suturing the capsule (capsulorrhaphy) together with permanent sutures and placement of textured implants tends to work very well.  In certain instances added reinforcement with acellular dermal matrix such as Strattice is required to help reinforce the repair. The textured implants help distribute the force on the tissues and acts almost as a Velcro to prevent the implant from migrating inferiorly and laterally.Hope that helps. You need to make certain that the board certified plastic surgeon you consult with has lots of experience with breast revision surgery.Good luck.

Allen Gabriel, MD, FACS · Answer

Thank you for your question.  Bottoming out is due to several factors and a discussion with your plastic surgeon is important in coming up with a good treatment plan.  In my practice the treatment involves use of some dermal matrix product to further support the implant/the overlying skin and correct pocket issues.  Please discuss this with your plastic surgeon. Best of luck.

David M. Creech, MD · Answer

The bottoming out problem has two methods of correction. Depending on your physical exam. This issue can happen after an augmentation, for patients that I have consulted concerning this issue I generally give them two options depending on their physical exam and review of the original surgeon's operative report. The first option I discuss and probably the most predictable long term correction is to implant a tissue called "Strattice" sold by LifeCell. This tissue implant is placed at the time of a revision by sewing the tissue implant to the edge of the Pectoralis Major muscle and to the Infra-mammary fold of the breast. The cleavage and "side boob" can be improved at the same time, depending on the underlying anatomy.

The second option is to internally correct the over expanded lower breast with internal suturing to re-suspend the infra-mammary fold.

The wide cleavage and the "side boob" can be improved, depending on the cause. Your surgeon can evaluate the possible cause and give you their thoughts.

The second option is to internally correct the over expanded lower breast with internal suturing to re-suspend the infra-mammary fold.

The wide cleavage and the "side boob" can be improved, depending on the cause.  Your surgeon can evaluate the possible cause and give you their thoughts.

Curtis Wong, MD · Answer

are evident and you have to choose whether you want the size you are (and leave thing as is until something happens that requires a revision) or to have more aesthetic breasts that would require downsizing and resecuring your fold back to where it was.  Your surgeon should be able to help you decide on what you need at this time.

Tom J. Pousti, MD · Answer

I am sorry to hear about/see the problems you are having after 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”).

It is probable that you are feeling the implants significantly along the lower poles of the breasts. Patients in your situation often complain of discomfort in the area of implant malposition. Also,  consistent with the breast implant positioning problem, the nipple areola complexes seem to be sitting relatively high, because the breast implants have settled too low.  Furthermore, the inframammary fold scars sit too high on the breast mounds secondary to the breast implants' displacement.

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 and visibility of the inframmammary fold scars should improve with this operation.The “internal bra” refers to a procedure where the breast implant capsule is utilized ( the procedure is called a capsulorraphy) to prevent the breast implants from moving too far downward or to the sides. Sometimes, the use of additional material such as acellular dermal matrix or biosynthetic mesh, may be helpful for additional support.

Ultimately, careful selection of plastic surgeon,  appropriate selection of  type of revisionary breast surgery,  skillful execution of the procedure, and careful attention to postoperative activity restrictions will be key to success.

I hope this, and the attached link (and video), helps.

Lori H. Saltz, MD (retired) · Answer

When folds are lowered and the inframammary incision is not secured bottoming out can eassily occur especially with smooth implants. The folds should be lowered carefully. Now the problem is getting the folds back up. This is not easy. Simple suturing of the pocket sometimes works, but often fails. You may need the addition of some sort of mesh or dermal graft support.Cleavage is a different matter. Your breasts are far apart and your implants are fairly centered behind your nipples along the horizontal axis which is where they should be. Moving the implants toward the midline will cause your nipples to be on the outside curve of the breast pointing outward. It's not a good look. You could ask to have your implants re-positioned more towards the midline, but don't over do it. Themuscle is attached along the breast bone and should not be detached to allow the implant to move inward. This can lead to big problems that are very difficult to correct.

Richard P. Rand, MD, FACS (retired) · Answer

There is an commonly promoted idea being circulated at national plastic surgery meetings that it is very routine to lower the IM crease when performing breast augmentations. In my opinion, this is a BIG mistake and that IM lowering should be used very sparingly and only for specific instances. The IM crease is the best barrier for implant descent and when you surgically destroy this barrier, the risks are much higher. You will need revision surgery by an expert with lots of experience. You look like your tissues aren't too thin to try a suture repair before resorting to the very expensive ADM products. In my experience with someone like you who has had surgery elsewhere, I would quote a 90% success rate with an internal suture repair PLUS wearing a specific underwire bra 24/7 for 3 months and avoidance of all pec muscle activities and bouncy exercises like running for 3 months. Also, you cannot go larger or the risk of the repair failing is higher. Repair will replace the incision back into the fold eliminating the bottoming out. The lateral drift would also be fixed and would push the implants closer to each other enhancing the cleavage. This would have been easier to have prevented in the first place but it can be repaired.

How to fix bottoming out & improve cleavage (Photos)

Answers (9)

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