Does risk of "bottoming out" increase if I start with very little breast tissue?

I had a consultation with a board certified plastic surgeon, and he told me that I should not choose the Inframammary fold as my incision point because I have very little breast tissue and the implant will bottom out over time if he cuts through the little tissue I have. Is this true? I am 25 yr old, 103 lbs, 5'2, barely a 32a, and getting 250cc silicone implant under the muscle.

Doctor Answers 15

Bottoms Up with the Underneath Incision

It sounds like your surgeon misunderstands the term "bottoming out."  It refers to a stretch deformity in which the nipple stays at the normal height, the crease under the breast stays in the proper place, but the skin between them stretches, allowing breast tissue or implant to fill that space.  Such breasts typically have nipples that tip up, an empty upper breast, and a full lower breast.That has absolutely nothing whatsoever to do with the incision.  In fact patients can have it without implants.  It is simply a matter of the weight of the breast  (tissue itself or implant) stretching out the skin of the lower breast. Heavier implants, saline implants, and more highly projecting implants tend to do this more.  
Your surgeon was probably confusing this term with "inferior malposition," which is what happens when the implant drops below the crease underneath the breast (the so-called inframammary fold or IMF.)   This can happen for a few reasons: imprecise technique, a poorly defined crease before surgery, a crease that is too high before surgery that needs to be lowered, a large and heavy implant putting pressure on the crease,  and weak tissues. Often more than one of these is responsible.This can happen with large and small breasts.  Small breasts are not more at risk unless you are planning on putting in a large implant which will require substantially lowering the crease under your breasts and your tissue is weak.  For your height and weight the implant you are planning upon does not sound unreasonable, but unless your breast is properly measured and evaluated it is impossible to know for sure.  It may be that you need an implant less than 200 cc.They are also incorrect about the underneath incision contributing more to this problem. Published studies show that there is a lower rate of implants being out of position with the underneath incision than any other incision.  It is the overwhelming preference of surgeons worldwide.I would suggest you find someone who better understands proper breast terminology and the mechanism of inferior malposition.The link to my website below discusses implant malposition.

Los Angeles Plastic Surgeon
4.8 out of 5 stars 44 reviews

Bottoming out

There are several reasons for bottoming out.  But the main one is placing an implant to large for your body and disrupting the IMF to fit the implant in.  The incision in reality has no bearing on this if the IMF is re-established.

Christopher Costanzo, MD
Thousand Oaks Plastic Surgeon
5.0 out of 5 stars 29 reviews

Preventing bottoming out

Implants can bottom out if:1. The plastic surgeon dissects the pocket for the implant too low2. The patient naturally have very poor ability to form a thick capsule and the weight of the implant pulls it down over time, usually more common with a big implant (because it is heavier)I personally don't feel that the IMC incision put you at risk for bottoming out, so I do find his comment strange. My best guess is that this has happened to him before and he probably blamed the incision location. If you are seriously worried you can wear an underwire for a month post-operatively as soon as the implant is in the perfect location, which usually happenes a few weeks post-op.

Lisa Cassileth, MD, FACS
Beverly Hills Plastic Surgeon
4.7 out of 5 stars 12 reviews

Bottoming out has nothing to do with what incision is used

and more important is the size and weight of the implant, the quality and presence of any predisposing problems (ie: tuberous breasts) with your tissues, and the technique used by your surgeon including how your pocket is dissected.  The fold can always be reinforced if there are any concerns.  You can either be cautious and go small or go for what you like, understanding the risks you are accepting if you do.

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

Yes and No

Women with small breasts tend to have larger breast implants inserted. The larger the implant, the greater the tendency for the breast tissues to stretch and for either the implant to drop or for the skin to stretch excessively. On the other hand, you are selecting a small implant. If the inframammary incision is used but the surgeon places supporting sutures that reinforce the wound closure, you should be fine.

George Sanders, MD
Los Angeles Plastic Surgeon
4.9 out of 5 stars 12 reviews

Bottoming out

The risk of bottoming out exists with anyone who has a breast augmentation.  While it is true than an incision at the IMF can increase this risk, the main factors at play are implant size (bigger the implant the greater the risk), failure to support the breasts, and genetics.  Incisions at the fold are actually ABOVE the fold and should not disrupt the integrity of the fold much at all.  250cc is a small implant and regardless of your "skin", the IMF incision should be just fine.

Tim Neavin, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 30 reviews

Bottomming Out

The amount of breast tissue that you begin with won't necessarily affect your risk of bottoming out. Surgical technique, including careful selection of implant size and dissection of the breast pocket are factors. If your Plastic Surgeon must lower or create a breast fold for you they will be concerned about reinforcing that area to prevent malposition. This is important and it could become a point of weakness if not handled carefully. I recommend that you discuss these considerations further with your chosen Plastic Surgeon.
All the best

Bottoming out due to Minimal breast tissue?

Thank you for your question Elle.

Having limited breast tissue alone is not a cause for bottoming out, but you would be more likely to have bottoming out when the inframammary fold is released and not firmly sealed and reinforced. The problem is that women with minimal breast tissue often do not have a defined crease which is why creating a pocket without releasing it can be difficult.

Bottoming out is also known as breast implant displacement and it results from the failure of the implant pocket where the breast implant slips below the natural or surgically lowered inframammary crease overtime.

A pocket can fail when there is loss of internal tissue support at the bottom half of the breast and this may lead to the breast implant to move downward on the chest, gradually lowering the natural bottom (crease fold) of the breast.

Clinical signs will include the implants ending up too low on the chest wall, the nipples will not only tilt upward as the breast implant heads down, but also be positioned higher on the breast mounds. Unfortunately, any inframammary scars from breast augmentation may travel up the lower breast mound. There will be no pain, but you may notice thinning of the skin at the bottom of the breast, which will allow you to more easily feel the breast implant.

An adequately created pocket can prevent this from happening. Also using the peri-areolar or transaxillary incision will prevent direct manipulation of the inframammary fold. After surgery, wearing a supportive underwire bra that applies pressure to the fold at the bottom of the breast may help prevent bottoming out.

To correct “bottomed out” breasts, a surgeon would need to secure the implant in an elevated position and then reinforce the implant capsule at the bottom of the breast with a suture technique. There may be a need for Acellular Dermal Matrix, a soft-tissue graft, in the repair. A smaller implant is often advisable, if the original was too large. In fact, receiving an implant larger than indicated by your breast characteristics and boundaries increases the risk of malposition. 

If you are comfortable with your surgeon and trust his opinion, take his advice. If you are a skeptical, then it is not wrong to get a second opinion before making your decision.

Hope this helps!

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 414 reviews

Limited breast tissue and possible bottoming out?

Thank you for your question.  Having limited breast tissue alone is not a cause for bottoming out in my opinion.  Trying to put too large an implant in place especially if you have limited distance between your nipple and the crease beneath your breast to permit such a sizable implant increases the risk of malposition in my opinion.  Being conservative in terms of your implant selection is wise.  My preferred approach is using either an axillary incision or a periareolar (nipple)  incision for placement of the implant and for better control of the inframammary crease region.  I also nearly always prefer placement of implants partially subpectoral in position. Sorry for all of the different opinions and confusing information that you are getting but as you can tell we each have personal opinions based upon our experience.  Make sure that you are comfortable with your selected plastic surgeon and again emphatically avoid too aggressive an implant selection for a better chance of an excellent long term result.Jon A Perlman M.D., FACS
Diplomate, American Board of Plastic Surgery
Member, American Society for Aesthetic Plastic Surgery (ASAPS)
Beverly Hills, California

Jon A. Perlman, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 29 reviews

Breast crease incision - will implant bottom out?

Thank you for asking about your breast implant incision.
  • I don't agree with your surgeon's explanation but I think you are a bit more likely to have bottoming out.
  • There are two problems if you are very flat, with little tissue and no defined crease.
  • First - a crease incision may be visible after surgery.
  • Second, in my experience, the implant is more likely to bottom out.
  • To reduce the risk, the crease can be reinforced at the time of surgery. 
  • Or the crease can be avoided at surgery using a nipple or axillary incision.
  • Both serve the same purpose - trying to avoid bottoming out.
  • If you do bottom out, you will need a crease incision to correct the problem. 
  • If you like your surgeon and trust his opinion, take his advice.
  • If you aren't sure, get a second opinion before making your decision.
Always see a Board Certified Plastic Surgeon. Best wishes  - Elizabeth Morgan MD PHD FACS

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.