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
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.
Placement of the
implants is too low on the chest wall
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
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.
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
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
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.
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
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
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 creasehelps produce an internal bra, which will
help support the weight of breast implants.
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.