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Bottoming Out with Breast Implants

 

 

Thin tissue or support at the bottom of the breast can weaken from the weight of the existing implant.  This forces the implant to migrate downward forcing all the fullness of the breast implant to be below the areola/nipple complex, and leaving the upper pole area flat. 

If the implant migrates downwards and starts bottoming out over a gradual period of time, then it is usually caused by thin tissue or the lack of skin in the underside portion of the breast.

 

Factors that contribute to "Bottoming Out":

  • Over-dissection of the implant pockets

  • Implants are too large and heavy

  • Placement of the implants is too low on the chest wall

  • Large weight swings and pregnancy will make your skin stretch, weaken, and become loose

 

Over dissection of the implant pocket made by the surgeon during the time of surgery usually will see bottoming out start almost immediately from surgery or within a few weeks. Over-dissection of the pocket area is a technical error, where the surgeon lowered the fold too much and the implant has now fallen to a very low position. 

The nipple/areola complex appears to move up on the breast mound pointing north, with all the fullness of the breast below the areola. Bottoming out is also caused by having large implants placed, especially above the muscle with inadequate post-operative support.  Bottoming out however, can occur with partial under the muscle (sub-muscular) - since with this placement 2/3 of the implant is placed behind the muscular wall - with the bottom 1/3 being supported with breast tissue.  Women who do not wear their supportive bras all the time take the risks of this occurring, as the weight of the implants on the tissue will eventually win out.

 

 

How "Bottoming Out" is Repaired:

  • The tissue surrounding the implant (the old existing capsule) is cut and rolled upward to the desired position of the new crease and held in place with internal sutures - also known as a capsulorraphy

  • Patients who do not have enough breast tissue for supporting the implant, can sometimes use AlloDerm dermis graft, which is rolled and sutured into place.   

  • A surgical method involving a patented mesh sling to support and bear the weight of the implant. 

 

 

 

Surgical Methods to Repair "Bottoming Out"

To correct bottoming out, the surgical procedure can vary, however all does require removal of the implants and revision of the pockets with internal sutures.  Bottoming out repairs can be difficult to fix, and normally either an internal capsulorrhapy is performed where part of the capsule is used to help reinforce the lower pole of the implant in the crease.  The reason why this surgery is difficult to perform is because more often than not, the capsules are very thin and will not tighten appropriately.

This advanced revision breast surgery technique is used to reposition breast implants that are either too far apart and are - laterally displaced”, too close “symmastia” or too low “bottomed out”. Several rows of tacking sutures are placed within the breast capsule to reconstruct the implant pocket, so that the result will be more aesthetic looking breasts.

Capsulorrhaphy can also be used to create a smaller pocket to preserve anterior projection and prevent lateral and inferior displacement when changing to a smaller implant.  Breast capsulorrhaphy is a safe and reliable technique for the repair of the most common breast augmentation complications.

If the patient does have over the muscle placement, then usually it is recommended to have the placement moved to sub-pectoral or sub-muscular to help with supporting the implant.  The site of the new elevated inframammary breast crease is selected preoperatively, and the inferior capsule is 'rolled' upon itself to close the pocket up to the point of the new fold, in which this is secured with several rows of permanent suture material. This closes the breast implant space, and after suturing doesn't allow the breast implant to descend.

This complication can occur with over the muscle placement and also partial under the muscle placement.  Having the implant placed completely sub-muscular will give the patient the best odds of not having this complication happen.

 

 

 

 

                                                Photos of Bilateral Bottoming Out:

                                          Bilateral Bottoming Out 

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  • Patient had over-dissected pockets from her first breast augmentation.  Please click here to see progression photos of bottoming out along with photos of her revision surgery to correct this problem.

 

  • Patient who had capsulorrhapy because of laterally displaced breast implants - please click here

 

  • See more photos of malposition or displaced implants here

 

 

 

 

A technique that is being used more often involves using a patented mesh sling to support and bear the weight of the implant.  Surgeons have been using mesh for years for hernias elsewhere in the body. The mesh helps with closing off the defect caused by the stretched tissue and can acts as a scaffold for new scar tissue to form. The scar tissue grows into the mesh, making the crease able to withstand the weight of the breast implant. Scar tissue growth is seen in as little as two weeks time.

If the patient doesn’t wear proper support at night with a bra, a second set of implant related problems occur. As the woman is lying on her back while sleeping the implants tend to migrate off laterally to the sides and fall into their armpits. This causes the breast tissue and the pocket to stretch out. Using the mesh sling in this area of the pocket – places vertically can close off this “lateral displacement”. Support on the sides is equally as important as below the breast mound. 

 

 

 

There are some surgeons who use Alloderm to help create an “internal bra” to help patients who have bottomed out. Alloderm is acellular dermal matrix derived from donated human skin tissue.  The tissue is processed to remove cells that might cause your body to reject the foreign tissue or react negatively to it. What is left behind is a collagen structure that acts as a frame for your own tissue to grow into and around. By placing Alloderm in the inframammory crease helps produce an internal bra, which will help support the weight of breast implants.

The Alloderm is used with implants in the partial sub-muscular, completely sub- muscular and sub-glandular position and is used to prevent medial, lateral and inferior displacement of the implant.

Alloderm is also used extensively for breast cancer reconstruction to help hide the implant edges and to give the implant support.

 

 

 

If the implant is too heavy for the strength of the tissue or the amount of the tissue that a patient has sometimes it is better to replace the existing implant with a smaller size, or possibly remove the implant altogether while the tissue heals.

The complication can be difficult to repair because of the fact the tissue available for reconstruction are thin and stretched.  Because of this, the tissue will not hold sutures well.  The recurrence of bottoming out after repair is always there as well.  Most plastic surgeons will use permanent sutures to make sure the repair stays.

 

 

 

Patient’s who do not wear their supportive bras during the day or at night, allow gravity to occur with pulling down the implants in an inferior position. This eventually will contribute to bottoming out or lateral displacement on the sides with the pockets and tissue stretching out. Wearing a bra at all times will help tremendously the longevity of your placement with breast implants.

 

                         

                                               

                        

 

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