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Advanced Art of Cosmetic Surgery Thomas M. DeWire, Sr., MD, FACS Specializing in Cosmetic Plastic Surgery |
Body Contouring |
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| 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-areolar 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. |  |
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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. | |||||||||||
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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. |
| Case 1 Problems | Analysis of Cause | Correction |
| Bottoming Out | Initial placement approach caused loss of lower pole support as muscle 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. | 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.. |
| Capsule Contracture | Contractile scar formation occurred causing firmness of the textured implants which had originally been placed via areolar approach. Avoid this by avoiding contamination of implants byStaph. 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. |
| 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: Correction of Implant Rippling
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| Link to another case of Correction of Bottoming Out: |
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| Maps to Office | Thomas M. DeWire, Sr., MD, FACS | E-Mail Dr DeWire |
| Advanced Art of Cosmetic Surgery | ||
| 3974 Springfield Road | ||
| Glen Allen (Richmond), VA 23060 | ||
| 804-290-0200 |
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| ©Copyright 1997-2007 Advanced Art of Cosmetic Surgery: Thomas M. DeWire, Sr, MD, FACS Revised October 29, 2007 04:06:06 PM |