Rippling and muscle deformity. Tissue is too thin. Options? (photo)

Hello and thank you for your question.
It is difficult to provide specific recommendations without a physical examination. However, based on your photographs, you have bilateral implant malposition with "double bubble" deformities. This is clearly worsened by activation of your pectoralis major muscles. I think you would certainly benefit from downsizing your current implants with more cohesive gel devices. I would also recommend changing the plane to the sub fascial position with the addition of galaflex. Fat grafting can also be added to help provide additional soft tissue coverage and minimize implant visibility. These procedures may need to be staged. You should consult with a surgeon certified by the American Board of Plastic Surgery who has extensive experience with breast implant revision procedures. Good luck. I hope this helps.

Dear lingf44,

though rare, some women who undergo breast augmentation will develop a minor deformity known as a “double bubble,” in which additional folds appear underneath the breasts due to the implant accidentally shifting or contracting post-surgery. In most cases, the implant simply slipped too far down the chest wall and traveled behind the breast inframammary crease (the area where the lower breast meets the chest), instead of moving forward to fill the breast cavity. If left untreated, the lopsided implant will form unnatural indentations, resulting in an odd “four-breast effect” rather than the full, rounded chest the patient initially desired.


Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

The type of animation deformity that you have requires the muscle to be re-attached, which can be done by converting from dual plane to the split muscle plane. This would enable the upper portion of the implants to retain muscle coverage while eliminating the deformity. You would need an internal bra with either Galaflex or Strattice to cover and support the lower part of the implant. Many examples on my website. A smaller implant will create a mismatch of the skin envelope to the volume of the breast, so not a good idea, but more cohesive would be helpful.

I am not a fan of what this surgeon did to you. It doesn't matter what plain an implant is placed (over or under the muscle), anatomic limits of the breast reign supreme in determining what size implant can be used, and your doctor used one far too big. The problem is this: no surgeon wants to tell a prospective patient no; they know you'll just go somewhere else and get the size implant you want. And therein lies the answer to your problem. You'll need to remove your current implants, tighten the pocket and reinforce that repair with mesh, and replace with new, smaller implants that match your actual breast width. This is the only way you're going to have breasts that have a normal appearance.

This is inframammary fold malposition due to placement of too large of an implant at the initial augmentation and likely over release of the sternal attachments/inferior origins of the pectoralis major muscle. Over time this implant stretched out the lower pole of the breast and the pectoralis major has ridden up (like a window shade being slowly pulled up over time). The crease across the lower pole of the breast is a combination of the previous inframammary fold and pectoralis major muscle that is over released. The new fold if below the crease as the implant settled into a final position. The best way to fix this is remove the breast implant and wait 4 weeks for soft tissue retraction. After 4 weeks, proceed to the OR for pocket tightening, fixing the fold malposition, inserting Galaflex, new implants that are slightly smaller, and removing some inferior skin of the lower pole.

You would definitely benefit from a revision with a smaller implant. This may be possible through a circumareola approach to tighten the skin envelope after the smaller implant is placed. At the same time, it is possible to put some fat into the breast to give more fullness to make up for the smaller implant.

Best Wishes,

Gary Horndeski, M.D.

Yes, go smaller with a gel implant and consider the muscle splitting procedure or placement under the fascia. You do not have enough tissue to place the implants just behind the breast, but this placement would decrease the muscle movement.