Is This Bottoming out Within 3 Months of BA? (photo)

I am 5'2" 118# 26 yo. I had a BA w 300cc silicone high profile style 20 implants. This was done dec 11 2012. I began noticing differences in implant position early on. My right was more lateral than my left. My ps now tells me I am bottoming out. Should I see if it gets worse before having it fixed and should I be getting more than $200 off on the price to reop?

Doctor Answers 10

Breast Implant Malposition With High Profile Implants


I am in agreement with Dr. Tholen with regards to his assessment.  You have a form of dropout, although it is more medial (inner) than lower.  Additionally ,there is some persistent muscular insertions on the inside of the other breast that could be released.  In other words, too much on one side, not enough on the other.

I would like to emphasize a point Dr. Tholen made, for those women who will be reading your post and our responses, for their edification regarding implant choices.  You are a classic example of someone with small, tight breasts who received a (relatively) large, high profile implant, and is having complications that will need a revision surgery.  Thanks to your very helpful serial photography, you can see where the preoperative issues might occur, and where the post operative problems did occur - 'hindsight is 20/20.'  However, given your body anatomy, you were never a good candidate for a high profile implant, and a smaller, intermediate profile implant would have been less likely to cause this unpredictable tissue stretch and subsequent implant malposition.

You are not a unique case, and every day women are getting high profile implants who would be better served with intermediate profile implants of the same diameter, so that the surgeon can 'stuff' more volume in. As you can see, more volume that is stacked on itself (high profile) is just as problematic as more volume spread over a wider area (mod/mod plus profile).

I am sorry you will need another surgery.  However, I am sure you will eventually get a beautiful result.

Best of luck!

Beverly Hills Plastic Surgeon
4.9 out of 5 stars 89 reviews

Breast Asymmetry

Thank you for your photos. You do not have "bottoming out".  In your preop photo your left breast is a bit fuller and has a slightly more laterally positioned nipple than the left.  Additionally your right breast seems a bit narrower than the left.  Implant placement makes your breast larger this magnifies your preop asymmetry.  There also could be some differences in the pocket size but only your PS can truly tell you if that is the case.

"Bottoming Out" is one form of implant malposition.

Your natural anatomy (pre-op photos; thanks for including) shows widely-spaced nipple/areola complexes; narrow-base/higher projection (high profile) implants need to be properly centered beneath your nipples to avoid malposition issues. "Proper" lateral positioning beneath your nipples would tend to give a wide-cleavage type appearance, which your surgeon tried to minimize with slightly more medial implant positioning.

As your healing-progress photos demonstrate, you now have inferomedial implant displacement (malposition) worse on one side than the other, which has become more visible as time has gone by. Your surgeon is being honest when he states this is a form of bottoming out. No surgeon can accurately predict the degree and extent of eventual scar stretch and pocket position for each and every patient each and every time--sometimes surgery is done "perfectly" and healing tissues stretch and allow undesired and unanticipated implant malposition such as you are demonstrating. Even when some degree of this is anticipated and accommodated-for with the operation, absolute perfection and precision of position is as much an art as science, and not one of us plastic surgeons here has received our perfection badge in the mail!

So now that revision surgery is anticipated, the question always comes up as to whom is responsible for what in terms of cost. Many surgeons (and I am in this group) will charge operating room and anesthesia fees (plus implants if needed) only for any kind of re-do surgery (no surgeon's fee).  $2700 for OR and anesthesia (depending on where the surgery is to be done) sounds about right, especially if at a hospital rather than in an accredited office surgical facility. Our no-surgeon's fee for a 1-hour general anesthetic re-do surgery would be around $2000 in our Minneapolis accredited office surgical facility.

This is something that should have been discussed PRIOR to surgery, so that touch-up or re-do surgery policy and costs are known ahead of time. Discuss cost issues with your surgeon.

As far as when to undergo revisionary surgery, 3 months is an absolute minimum, but waiting 6 months (or longer) will allow your surgeon to more accurately gauge just how much you will ultimately "settle" and drop, and may help to more precisely "over-correct" the ideal amount for optimal final implant position and appearance.

I would defer to the surgeon personally examining you, but would suggest same-size implants (if you like your present size) but consider switching to moderate plus profile implants or even moderate profile implants, which will provide more base width for identical implant volumes. You will still need bilateral inferomedial capsulorrhaphies (suture tightening of the capsule ) and probable lateral capsulotomies (opening up of the lateral pockets) for improved implant position beneath your nipple/areola mounds and adequate implant mobility and softness.

Your problem is one that is not rare, and can indeed be significantly improved-upon if not "fixed." Talk with your surgeon. Best wishes! Dr. Tholen

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
4.9 out of 5 stars 255 reviews

Pre-existing asymmetries in breast augmentation surgery

You have a fair degree of asymmetry of breast shape and size.  Your left breast is smaller and the nipple is lateral to the meridian of the breast.  I do not feel that this is bottoming out rather it is about the expected result considering your pre-existing asymmetries.  

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 19 reviews

Bottomin out ? not ?

I don't really think so...but I can't tell without seeing you in person and better photographs....what I really think is you have had an augmentation that augmented your asymmetry...   your left nipple areola complex was lateral to midline before surgery and it's augmented after surgery..... an attempt to medially position your nipple areola could be done but at the cost of scarring, risk of implant exposure and loss, and the need for multiple procedures....again may have bottoming out but that is not what I can see with what I have been given.  I hope this helps.  Regards, Dr. Weiss

Alan Weiss, MD
Baltimore Plastic Surgeon
5.0 out of 5 stars 2 reviews

Is This Bottoming out Within 3 Months of BA?

I find myself looking at a nice result. There is some asymmetry, but less than before surgery. The right breast, nipple and areola are more lateral in the before photos, and still are but less so. 

The photo on the right has the best chance of showing bottoming out but the area in question is too dark to see. I really see no suggestion of bottoming out, and I would be reluctant to recommend further surgery. 

All the best. 

Jourdan Gottlieb, MD
Seattle Plastic Surgeon
4.6 out of 5 stars 45 reviews

Bottoming out three months after augmentation

We can't tell from your photo about bottoming out, though it usually is an issue of implant postioning at just three months and not a gradual bottoming out. Your photo does show an asymmetric skin envelope, and some of the same tendencies after your implants. At this point your breast is not really so bad, and revision is something that should have very sound planning and acheivable goals. You might want to relax and see how your result sorts out after a year or so and then think about what you don't like and what to do about it.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 42 reviews

Is this bottoming out?

It is hard to tell from the shadowy photos.  Bottoming out means an abnormal lowering of a breast implant to a position lower than desired.  If your surgeon thinks it is, it probably is.

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
4.8 out of 5 stars 67 reviews

Bottoming out?

You have a very wide chest bone and, as a result, a very wide cleavage.  It looks like your plastic surgeon tried to give you more cleavage, however, only bad things can happen when this is done:  1.  There is not much over the chest bone other than a thin layer of skin.  When this skin is undermined, there is a greater chance for seeing/feeling ripples in the implants.  2.  The implants are placed too far medially (towards the chest bone) and not centered under the areola as they should be.  This results in nipples that point to opposite walls like yours do.  This can be corrected using stitches inside the breast implant pocket to re-build the cleavage area back to its original position.  I might also open up the pocket more laterally (towards the armpit) so that the implants are more centered behind your breast tissue and areolae.  Breast implants are designed simply to add volume to the breast and should not change the basic shape of the breast.  With that in mind, I don't mess with the cleavage area when I do breast augmentations.  I tell my patients that implants will give you more volume but push-up/push-in type bras will give you more cleavage.

Edwin C. Pound, III, MD
Atlanta Plastic Surgeon
4.8 out of 5 stars 24 reviews

Bottoming out?

There is a lot of shadowing in the photos so it is hard to tell. It does not look like that  from the view  posted.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

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.