What is the cause of low nipples after breast augmentation - "Waterfall Effect" also known as "Snoopy Deformity"? (photos)

Hello and thank you for your question and photographs.  To echo some of the points already raised on this panel -- I think the first photo shows breasts with an incomplete release of the lower pole, potentially requiring further dual planning or a lift.  The second photo shows a good result and the lower pole will settle down further.  The third photo, though attractive, may end up with further elevation of the nipple, which is already quite high (as you can tell with how close the areola is to the tan line in the bikini). 
The next step for you is to seek out a board certified plastic surgeon who specializes in aesthetic plastic surgery.  In your consultation, be sure your surgeon addresses all your concerns and discusses the surgery details including the position and size of the incision used, the type of breast implants available, the risks and benefits of the procedure, recovery time, and post-operative course.  Also, be sure to see plenty of before-and-after pictures in women who have a similar breast appearance to yours, and preferably at different time frames (3 weeks out, 3 months out, etc) to more accurately predict your own surgical outcome.

And lastly, I think the most important component of the consultation is to establish a good connection with your plastic surgeon, to clearly define your desired breast outcome goals. If you don’t feel you have a good connection with your plastic surgeon after your consultation, he/she may not be the best surgeon for you.

For more questions about a breast augmentation, please refer to my link below.Good luck.

Mark K Markarian, MD, MSPH, FACS

Harvard-trained Board Certified Aesthetic Plastic Surgeon

Hello, you correctly listed some possible reasons for the "waterfall" or "snoopy dog nose" shape. It can result from pre-existing sagging with low nipples, a short nipple-to-fold distance so the implants can't drop and fill in the lower part of the breasts, an issue with the surgery itself (like not making the pocket low enough, or the type of pocket chosen), or even an issue with the healing process such that the implants don't settle normally.

You do not see this as much when you have a small amount of your own tissue (A or B cup) because there is not as much “weight” to your tissue, so gravity does not affect your natural tissue as much. Other factors such as major weight changes, pregnancies, and breastfeeding can also exacerbate the snoopy deformity.  A breast lift should correct this problem.

Hi.  I pretty much agree with all of the points made already by Dr. Stoeckel.  In the first photo it might be that things were not released as much as they could have been along the lower pole, but it might also be just that she has really tight tissue there.  I have seen cases where someone tried to lower that fold more than what is reasonable based on the patient's anatomy, and they end up with a bit of a band effect from where the old inframammary fold was but where it just could not loosen up enough to be smooth in contour.  That ends up looking not so great, and can be tricky to fix.  I think the second result is actually very reasonable based on the anatomy I see and that picture.  The lower part of the breast in that picture will likely relax over time.  In the last photo (again it is all a matter of personal preference, and yes I think they are attractive breasts), but those may well end up being bottomed out and too stretched out in the lower part of the breast or the lower pole in fairly short time.  Just my thoughts on all that based purely on the pictures.  I would recommend consulting with a board certified plastic surgeon with good experience with breast augmentation to help guide you through the process and give you good advice specific to you and your examination and your anatomy.  Good luck and take care, Dr. Howell

It appears you want perky fully formed breasts. It would be helpful to see your existing breast to help determine what can be done to get the result you want. Sometimes a tight inframammary fold prevents the look you seek. There are ways of altering the lower pole of the breast that can create the look you seek. Good luck...

Thank you for your question and photos. The answer lies with breast proportions. The nipples are not “low”, but the distance between the inframammary fold and the nipple is too short. Or, the fold is not low enough, or the implants are too high in relation to the nipple. In the early post operative period it may be helpful to apply an elastic bandeau across the top of your breasts to help lower them. Please discuss your concerns with your plastic surgeon.

I am not sure that the examples that you have shown would truly be considered what most surgeons refer to as a "snoopy deformity", but I do understand what you are asking. You would like to know how to make sure that your implant sits low enough on your chest wall to make sure that the nipple does not look like it is on the lower pole of the breast. The answer is going to be determined both by what you look like before surgery and how your surgeon places the implant. The examples that you have shown that you do not like are probably just early results (less than 3 months) after surgery. Most likely, those examples will look closer to your goal with just time as the skin of the lower pole stretches and accommodates for the implant. But if the tissue in the lower pole is not softened or released some during the development of the implant pocket, it is possible for implants to become arrested slightly high on the chest and for them to continue to look like the examples you don't particularly care for. The example that you do like is actually getting close to being considered "bottomed out". It looks good in the photo, but might just be an amount of time before it looks too low on the chest and the nipple appearing to be unusually high on the chest. I would be cautious when talking with your surgeon about being aggressive with the lower pole dissection, because it can easily turn into a situation where you are returning to the OR for a revision procedure. 

Hello and thank you for your question. It would be useful to see the pre op images and also your current photos to give you a better advice. Careful pocket dissection and appropriate implant selection is needed to allow for lower pole expansion and creation of natural results. One of the reasons of low nipples is the existence of some degree of breast ptosis prior to breast augmentation, in which case patient would have likely needed some type of a breast lift. Another reason is incomplete pocket dissection, where the implant don't have a chance to fully drop. Or this could simply be related the early post op period, when the implants still have not full dropped; in this situation the result should get better over the coming weeks. Encapsulated implants also tend to sit high post op making the nipples stay low. I would seek consultation with a board-certified plastic
surgeon for a full evaluation and advice. Best,
Pejman Aflaki, M.D.                                            
Johns
Hopkins-trained double board-certified plastic surgeon

Snoopy deformity is usually the result of placement and the way the implants interact with the breasts that are a little droopy. I don’t see your photos posted but if you have no droop then this deformity should not be high on your list of concerns.

Dear Adventurous4058,
Careful pocket dissection, implant choice and placement are very important to achieve the desired results. Breast implant type and sizing selection is a complicated process and requires a detailed consultation that includes a discussion of your goals, a detailed examination, and a lengthy discussion. But the decision will always start and end with the patient. 
When it comes to sizing, we have all of our patients find 3 photos of their desired breast size. We ask for naked breast photos because clothing can obscure the true size (push up bras). Next, we consult with patients and go over the photos and take detailed breast measurements during a physical exam. Next, we using a sizing algorithm to determine a range of implants that will work based on the exam and the measurements.Lastly, during the operation, we use silicone sizers in the operating room to see how the size actually looks in the breast. We sit the patient up in the operating room, while asleep of course, and compare the sizer result with their desired look photos. If it is too small, we start the process over with a slightly larger implant. We don't stop until we get the perfect match.Of all of my breast augmentation patients, every one of them has been happy with their size due to this detailed and meticulous process. You don't want to invest time and money into a result that is either too big or too small.You should discuss your concerns with a board-certified plastic surgeon and make sure that your surgeon understands your goals.
Daniel Barrett, MD

Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery