I am 4 months post-op with 325cc hp placed subpectorally. I am 5'2, 115 lbs w/ a pidgeon chest and athletic. I have nursed 3 children. My problem is 2 fold. My left breast has bottomed out (within the first month). My right breast is far out laterally. Due to the spacing of my breasts, I am in pain on my right side. The right side is slightly bottomed out as well. I cannot find bras to fit. My surgeon wants me to go with a smaller implant (280cc or 300cc)& move them to a subglandular position. Is this appropriate?
Downsizing and Subglandular Placement to Fix Bottomed out Breast Implants?
Doctor Answers 17
Correction of implant problems requires a very customized approach
I'm sorry to hear you're having problems after your breast surgery.
I agree with my colleagues that because you have a pectus deformity, and because you are athletic and active, you are predisposed to having your implants slide laterally.
Correction of problems after breast augmentation requires a very customized approach and I personally am not comfortable making recommendations to you by email or in this forum...
I would suggest that if you are interested in other opinions of what would be appropriate for you, that you visit a few other board certified plastic surgeons for consultations... I do not necessarily think that placing the implants above your muscle is in your best interests though.
Revising a breast augmenation
Hello - Changing the pocket of the implant is one way to improve the position of the breast implants. You also may want to consider internal suspension sutures, smaller implants, or a lift if needed. It's hard to say without seeing photos and/or examining you. However, it's also important to make sure the swelling has resolved after your surgery to really get a good sense of where the implants are positioned, so you may want to wait several months before any revisions.
Displaced breast implants
Bottoming out post breast augmentation is not an uncommon problem. There are several different ways of correcting bottoming out. The method I favor is to use the same implants if they are gel and place them in a subglandular (subfascial) position.
If you have saline implants and don't want to switch to gels, I would reposition the implants and close off the pocket inferiorly by recreating the breast fold. This requires more healing and downtime. Your exercise would be restricted for 4-5 weeks. You should discuss your options in detail with your surgeon so that you fully understand all the ramifications.
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Implants bottoming out
To answer this properly I agree with one of the answers that pictures would help define whether there is bottoming (stretching out of the lower breast, lowering of the inframammary crease, lowered implant position, or a combination) or the problem is malposition of the implant or possibly an improperly sized implant (the width of the implant was too wide for the breast like a foot being too long or wide for a shoe).
I disagree with another answer that subpectoral positioning of the implant helps to support it (the fascia can do this but not the muscle). If the pectoralis muscle edge is not adequately released it can actually cause bottoming and double-bubble contour deformity but I agree that changing to subglandular positioning is not the best solution.
Assuming the implant was sized properly, positioned properly, and healed in the proper position, and the problem is pure bottoming, the solution is to reestablish the proper position of the inframammary crease, raise the implant up, and shorten the lower pole length of the breast. This can be done with the same implant or a more projecting one but shouldn't be a wider or narrower implant. It is necessary to verify that the capsule around the implant has not closed down in the upper pole and will allow the implant to move up. An inframammary crease incision is recommended (which is one reason to use it for the primary augmentation) and the stretched out capsule must be stripped out and oversewn to hold the implant at the proper level. The lower side of the inframammary crease incision must be secured to the chest wall and often the dead space where the old capsule existed must be tacked down to the chest wall using external mattress sutures. The elastic strap of the bra is then kept over this area for two weeks to help hold and heal it in the proper position. I call this procedure "re-tucking the crease". It is also useful in correcting double-bubble deformity along with releasing the inferior edge of the pectoralis muscle.
To specifically answer your question, I would not agree with a solution of a smaller implant and subglandular positioning unless the original implant was too wide and the surgeon doesn't know how to release the pectoralis muscle properly or do a crease tuck procedure. The description of lateral displacement of the implant is a malposition problem and is much more difficult to correct. The newer techniques of neocapsular/pocket formation might be required. This might, in effect, be a change to a subglandular position for the implant.
Chest shape and bottomed out implants: revision surgery.
Placing an implant under the muscle generally provides additional support to the implant. I worry that placing any implants above the muscle will further aggravate your bottomed out implants. Your chest shape further predisposes you to this tendency. If you undergo any revisionary procedures I would advise wearing a bra to bed at night to minimize this tendency.
Downsizing and subglandular placement
I appreciate the other expert posting. But I for one need to see photos (before and after). This will allow me to see the differences and more accurately see the problems.
Regards Dr. B from MIAMI
Implants moving downward and off to the sides
Patients with loose skin, widely spaced breasts, and those with a chest wall shape like yours will have a tendency to have the implants move "down and out."
My approach to this (which works well in weight loss patients who have LOTS of loose skin) is to consider placing a smaller implant in the pocket after it has been stitched to close off the lower and lateral areas.
Equally important is avoiding bouncing, shaking, etc. (i.e. jogging or high-impact workouts) and wearing very good support until the pockets have healed.
Craeting a new pocket is unnecessary, in my opinion.
Fixing bottomed out breast implants
Your own chest wall anatomy has predisposed you to having the implants slide laterally, the slight bottoming out is another issue and can come from simple implant descent. In order to correct this, you would need to tighten the pocket laterally and inferiorly and go with the same or smaller implants so as to reduce the risk of recurrence. The problem with a pigeon chest and implants that are already widely spaced so that going smaller will also potentially widen the space between the breasts. Until you have tried at least one fix under the muscle, I wouldn't go to the prepectoral pocket just yet. Not an easy starting point or fix. Make sure you have an experienced breast surgeon here.
Bottomed Out, Laterally Fallen Breast Implants
Although VIRTUALLY any implant could feasibly be placed into most women, it really does not mean that they should be.
In your case, the side sloping of your chest ( IE Pigeon chest) means that EXTREME care needs to be taken when the breast implant pockets are NOT overly developed sideways. Instead, the side walls need to be left alone and undermined slowly and incrementally to prevent what you describe. However, sometimes this happens despite good pocket dissection. On the other hand, bottoming out of breasts is largely related to over-dissection / undermining of the 4 O'clock to 8 O'clock portion of the implant pocket and weakening its ability to hold the implant. As a result, there is progressive inferior shifting of the implant.
In my opinion, there is no great reason to switch to a sub glandular pocket. The bottom of the present pockets and the side walls needs to be reefed/repaired (CAPSULORRAPHY) to hold the implants higher and more centrally. Smaller implants would lessen the weight on the repair. Without a photograph or an exam I cannot comment as to if the same size implants could be used again.
Correction of malpositioned breast implants
Every plastic surgeon who performs breast augmentation will occasionally have a patient who has malposition of the breast implants. Correction can sometimes be difficult. I do not think that there would be a significant advantage to making a relatively small change in the size of your implants or in placing the implants in a sub glandular position. Usually the implant position can be corrected by adjusting the existing pocket.
This involves excising and repairing the excess capsular tissue in the lower and outer parts of the pocket. Wearing a snugly fitting underwire bra postoperatively helps support the breast implants to allow the repair to heal properly. Sometimes, it might be necessary to reinforce the repair with a product such as Alloderm or Flex HD. These products can act as a sling or hammock to help support the breast implant if the patient's tissues are not substantial enough. Discuss the above possibilities with your surgeon and perhaps another experienced breast surgeon.
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.