Advanced Art of Cosmetic Surgery     Thomas M. DeWire, Sr., MD, FACS    Specializing in Cosmetic Plastic Surgery     Richmond, Virginia, USA



         Advanced Art of Cosmetic Surgery     Thomas M. DeWire, Sr., MD, FACS    Specializing in Cosmetic Plastic Surgery     Richmond, Virginia, USA

Breast Implant Procedures

Breast Augmentation Revision Surgery
Correction of Implant Displacement with Implant Bottoming Out


Implant Displacement with Bottoming-Out:
Implant Bottoming-Out  is seen when the implants end up too low on the chest wall and  the  nipples end up positioned too high on the breast mounds, tending  to pop up out of a bra or bathing suit  top.    It  is  the  loss  of  internal  implant  support where   implant    placement    with   partial,    or   no,    muscle coverage,  allows slow downward  migration of the implants.  This is because  support of  the implant  by  the skin alone is not  always  enough  to  prevent  downward  migration of  the implants.   Also,  over-dissection  of  implant  pockets  at  the  time  of surgery may cause  immediate  Bottoming Out ,  with  too-low position  of  one,  or  both,  implants.   Bottoming  Out results  in  too-low  positioning  of  the  breast  mound  on  the  chest  wall,   and  too- high  positioning  of  the  nipple  on  the breast  implant,    which   has   fallen   down  from  behind  the nipple.   Bottoming Out  is seen to some extent,  over time, in most implants  placed  via crease  incisions,  and  probably by  the  peri-areola   route   as  well,   with  apparent  upward migration of  the  lower  crease scar, onto the  breast mound,  as the lower pole tissues stretch, or separate away from the chest wall,   letting  the implants  fall.    Bottoming Out  occurs more frequently with breast implants over or  partially under the muscle, and will rarely occur with implants totally behind the muscle, especially if internal sharp or cautery dissection has  been   used   to  release   and  form   the  lower  pocket.


Case 1:  A 34 year old woman 6  years  after  textured  saline implant      augmentation    via areola      incision    approach resulting  in   partial  muscular coverage of  the  implant  with subsequent bilateral capsule contracture      and      bilateral Bottoming-Out,  worse  on  the left,  with  upward  malposition of   nipples.    These  textured saline      implants,     partially sub-muscular,  were wrinkled, and  felt quite unnatural  to the touch.      In    my   experience, textured     implants    do    not prevent capsule  contracture, and   furthermore,    they   are MUCH more firm than smooth implants    maintained   in   an oversized   pocket.
 Age:  34
Ht: 5'4"   Wt:  120 lbs.
Old Implants: Mentor 
Type:  Textured Saline
Vol: 225cc R / 250cc L
Size:  36 B/C
New Implants:  Mentor
Type: Smooth Saline
Vol:  425cc R / 450cc L 
Size: 36  C/D




Correction was accomplished by partial removal and partial cutting of the hard peri-implant capsule,   opening   up  of  the upper   poles   of  the  implant pocket, and  then repair of the lower   fold    by    folding   and suturing of the lower aspect of the  capsule.   Larger  smooth saline    implants    were   also inserted,   thus completing the correction.       Smooth   saline implants allowed  for  a  much softer    result,     as    well    as preventing      the      tendency toward  visible   rippling  seen with  textured  saline implants. The    inframammary    crease approach       was     used     to facilitate   the  direct  repair  of the  lower   folds  equally  and symmetrically.         The      left crease was raised  3cm,  and the   right   was  raised  1.5cm, thus  restoring  correct  nipple position, centered on the new larger breast mounds.
Photos   show   the  massage displacement     of    the   new implants,  keeping them  very soft  by   limiting  formation  of scar  tissue  directly adjacent to the shell of  the implant,  the reason   that   textured   saline implants tend  to  always  feel much   firmer  to  the  touch.
See: Implant Massage Page
Case 1 Problems Analysis of Cause Correction
Bottoming Out Initial placement approach caused loss  of lower pole support as  muscle origin fascia  was cut to place the  implants   in   the   submuscular  plane.    This allowed  later  stretching  of  the  lower  pole  skin, thus allowing the  implant  to  displace downward, or  bottom-out, rotating the nipples upward. Release capsule contractures to establish  widely patent implant pockets, followed by restoration of the lower folds by permanent suture repair.   Avoid by placing implants in  completely submuscular plane to preserve internal implant support..
See Implants Over versus Under the Muscle
Capsule Contracture Contractile    scar    formation    occurred   causing firmness   of   the   textured    implants   which   had originally   been   placed   via  areola  approach. Avoid this by  avoiding  contamination of implants by Staph. germs which may be encountered while passing  through the breast tissue ducts and skin.  Release and remove  scar tissue to allow a large implant pocket to be established, and then  use  post-op  massage  techniques  to prevent  recurrent  capsule  formation.  
See Post-Op Implant Massage Technique
See Capsule Contracture Correction
Visible Implant Wrinkling Textured saline  implants  are inherently thicker than smooth implants  and  are  both  firmer and more  prone  to  visible  wrinkling.    This is even more true for textured implants  placed over the muscle  and  in  thin  soft  tissue  coverage. Replace the thicker textured implants with softer smooth implants.  Lower likelihood of wrinkling even further by exchanging for submuscular smooth silicone gel implants.  Size upgrade was easy with larger pockets and symmetry was provided by adjusting  the final implant volumes.
See Improvement of Rippling


Link to another case of Correction of Implant Bottoming-Out
Photo Gallery of Bottoming-out reconstruction cases
Back to Augmentation Revision Page


Related  Breast Augmentation Links:   To Other photo Illustrated Procedures:

Important  Information  About  Implant  Breast  Enlargement

Trans-Axillary Breast Augmentation
Trans-Axillary Breast Incisions Scars
Breast Augmentation Shape Evolution
Breast Augmentation Shape Determination
Cleavage Determinants
Post-Op Implant Massage Technique
Implants Over versus Under the Muscle
Special Considerations in Augmentation
Breast Surgery in African American Women
Breast Augmentation FAQs
Breast Augmentation with Mastopexy or Breast Lift
Revision Surgery for Augmentation Problems
Important Information about Silicone Breast Implant Use
Nipple Reduction/Shaping
Mastopexy or Breast Lift

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Thomas M. DeWire, Sr., MD, FACS
Advanced Art of Cosmetic Surgery
3974 Springfield Road
Glen Allen, VA 23060
Richmond, Virginia, USA
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ęCopyright 1997-2013  Advanced Art of Cosmetic Surgery:  Thomas M. DeWire, Sr, MD, FACS   Revised:   January 23, 2013 12:30 AM