Thanks for your question. Basically, your tissues themselves. When the implant is a scar sac (capsule) is formed around the device. In most patients, this capsule will help keep the implant in place. However, with age, time, gravity, and tissue stretch to age/pregnancy, the tissues will start to fall. The extent varies widely between patients. I have seen 55 y/o women with perky breasts and 22 year old women with very saggy breasts. When the implant is placed under the muscle, the muscle helps keep the implant in place, but the breast tissues will sag and give the "snoopy breast." If the implant is placed on top of the muscle, the breast and implant will fall together giving the "rock in a sock" look. Some women, a few %, will not develop a good capsule and their tissues will stretch and "bottom out" early. You cannot predict to whom this will occur. Picking an appropriate sized implant and not over-dissecting the implant pocket are things that can be done to help avoid bottoming out. Good luck.