Treatment of Bottoming out Following Breast Augmentation

What the lower pole does when an implant drops

Bottoming out is an undesirable increase in lower pole prominence after breast augmentation, or after a lift done with an implant. The lower breast skin stretches, the implant shifts into the lower pole, upper pole fullness is lost, and the nipple and areola point up. The implant descends below the natural inframammary crease, and the nipple sits too high on the mound.

The same drop can follow an implant alone or a lift combined with an implant. Treatment of bottoming out following breast augmentation is planned only after the cause is identified. The American Society of Plastic Surgeons describes breast augmentation as the use of breast implants or fat transfer to increase size and roundness. The maneuvers below are for an implant that has dropped below the crease.

Early descent and later stretch

Within six months

Early bottoming out occurs within six months and is attributed to surgical error. There are two common causes. The first is an implant too large for the nipple and areola to sit centered on it. Once that implant is positioned, it looks high riding because its lower half will not fit the lower half of the mound.

The surgeon then lowers the inframammary crease. Once that crease is violated, its integrity is hard to keep. The second early cause is a lower half of the mound that was designed too long during a breast lift.

Later stretch of the lower skin

Late bottoming out has two main causes. The first is gradual stretch of the lower breast skin and soft tissue when a generous implant is chosen. Repetitive bouncing sports such as running can make that drop appear earlier. Thinned breast skin and soft tissue are a further reason stretch is more likely.

Patients who have had a breast lift are the most vulnerable, because performing the lift thins the lower pole.

Elastin, ptosis, and who is more vulnerable

Poor elastin is the late cause most often named for treatment of bottoming out following stretch that shows up after the early months. That composition is described as mostly genetic and not alterable. If stretchy skin is seen before surgery, the lower skin is tightened more aggressively during a lift, or a smaller, more conservative implant is chosen. Skin that has always felt stretchy is the pattern tied to this side effect. Elastin density falls with age. Elastin is the recoil protein in skin. Elastin production is said to stop by age 45.

Large implants raise the strain on breast tissue and skin. Aging, hormonal changes, breastfeeding, and weight loss are also named as factors that change tissue and skin integrity. Limited skin elasticity, natural breast ptosis or laxity, a mastopexy, and breastfeeding make it harder for the skin to support the weight of an implant. Inadequate tissue support, an implant placed too low, and skin laxity are the mechanisms named for the drop.

Measures named for poor skin integrity are internal sutures or supportive materials, a smaller implant, or a combined lift. A heavier implant puts more pressure on the lower pole, so size is chosen against the body frame and the existing breast tissue.

Treatment of bottoming out following a stretched lower pole

The specific repair uses several maneuvers. A wedge excision shortens the lower pole, removes lower pole fullness, and includes an inferior pole lift. A smaller implant reduces the shear weight on that pole. Treatment of bottoming out following a crease that was lowered means putting that inframammary crease back. If the original lower horizontal incision was not repaired properly, the crease is reinforced with deeper stitches.

The same problem is also described as pocket modification or pocket reinforcement, and as removal of the implant with replacement by a smaller or more supportive implant. Breast augmentation revision surgery is the setting for that pocket work. Risks named with those options are infection, bleeding, sensation change, scarring, implant rupture, shape change, malposition, and the need for further revision.

Support garments and exercises that strengthen the chest muscles are listed with revision as ways to treat or prevent the drop. They are separate from the wedge excision, the smaller implant, and the crease repair. Activity limits after surgery, and use of the support garment, are the prevention steps listed with them. Risk factors named alongside those steps are a large implant, inadequate tissue support, improper surgical technique, thin breast tissue, and activity that strains the chest muscles.

Shell, fill, and where the implant sits

The shell holds the silicone or the saline filling, and that shell is what stands between the fill and a leak or a rupture. Saline implants are filled with a saltwater solution and are described as firmer. Silicone implants are filled with a cohesive silicone gel and are described as having a more natural feel. A longer comparison of the two fills is on the silicone versus saline page.

Textured implants are associated with breast implant associated anaplastic large cell lymphoma, called BIA-ALCL. The FDA states that the risk of BIA-ALCL is higher for textured surface implants than for smooth surface implants. There has been a shift toward smooth implants with a nano-textured surface, such as Motiva. That surface is believed to lower BIA-ALCL risk. It is also credited with a lower risk of bottoming out, more stability, and a more natural feel.

Placement under the pectoralis muscle is described as reducing bottoming out, because the muscle spreads the weight of the implant. Placement on top of the muscle is described as increasing tension on the skin and tissue, and as raising the chance that the implant will drop below the crease. A larger implant adds strain on the surrounding tissue, so size is part of that placement decision.

A mastopexy combined with augmentation raises the risk of the implant dropping. The plan named to lower that risk is two stages: the lift first, time for the breast to heal and settle, then the implants. Healing first lets the surgeon see the settled shape before implant weight is added. Doing the lift and the implant in one operation is the combination tied to the higher risk. Timing for a breast lift with implant augmentation is covered on its own page.

Running, lifting, and capsulorrhaphy

Running, jumping, and vigorous exercise can displace an implant, and a supportive bra is the measure named for those activities. Weightlifting and tennis repeat arm motion and can also move an implant. Other risk factors named here are improper implant placement, excessive scarring, and postoperative complications.

Implant exchange and capsulorrhaphy are the treatment of bottoming out following displacement. Capsulorrhaphy is listed as a positioning repair.

Signs on the chest

The implant shifts down, the nipple looks higher, the shape changes, the two breasts may not match, and the implant feels lower on the chest. Those are the signs named for a dropped implant.

Sharp pain, pressure, and a stretching sensation in the lower chest can occur with a deep breath, with bending, or with lifting. Pain that continues, and that interferes with ordinary tasks, is a reason to contact the surgeon.

Double bubble deformity is corrected by releasing the constricted tissue, repositioning the implant, and possibly adding a supportive mesh or an internal bra. Complications named for that correction are asymmetry, loss of sensation, and implant displacement.

Volume loss in the upper breast is attributed to aging, significant weight loss, pregnancy, or breastfeeding. The upper pole looks flat or deflated, the skin can look stretched or thin, and the nipples look too high on the mound. Correction named for that pattern is revision of implant position or size, plus reshaping of the breast tissue. Synthetic mesh scaffolds are mentioned as extra support. A lift may be used to reposition the breast.

A rising inframammary scar can look as if the scar itself is moving up the breast. Measures listed are scar massage, topical treatment, or scar revision. Care listed with those measures is keeping the area clean and dry, using prescribed medications, and avoiding strain on the scar.

Pressure on the lower breast tissue can shift the implant downward and pull the nipple upward. The nipple then sits higher on the breast, at a steeper angle than before. Tight bras or clothing, the weight of the implant, and poor placement are the causes named for that upward nipple.

Bottoming out compared with sagging

Bottoming out and breast sagging are different. In bottoming out the implant sits below the natural breast crease, the lower pole bulges, and the nipple sits too high on the mound. Oversized implants, poor surgical technique, and decreased tissue support are the causes named for that drop.

Sagging, also called ptosis, is a droop of the whole breast, with the nipple pointing down and a loss of firmness. Aging, pregnancy, weight change, and genetics are the causes named for ptosis. Bottoming out makes a lower pole bulge with a high nipple. Ptosis is a gradual droop of the entire breast.