Bottoming Out and Implant Malposition
Although some idea of the final look of the breasts can be appreciated three months after an augmentation, it often takes eight to nine months for everything to settle and reveal the “final” appearance. The ideal breast might have 55 percent of the breast volume below the plane of the nipple. However, sometimes the implant stretches out the tissue on the underside of the breast too much or does not settle in the correct position.
What Is Bottoming Out?
“Bottoming out” is an inferior displacement of the implant wherein the implants stretch out the lower part of the breast too much and may also settle too low. The breast mound may be in the correct position, but the nipple and areola are too high, or the implant and fold settle too far down on the chest wall. In a “bottomed out” breast, more of the breast volume/implant is below the nipple, giving it a “too low” or drooping appearance. In more severe cases, the nipple seems to float on top of the breast mound and point upward, which is often referred to as “star gazing” nipples.
Causes for Bottoming Out
Although there are many factors that might contribute to bottoming out, most relate to the nature of the patient’s own tissues and how they respond to the surgery. Bottoming out occurs when the tissues stretch more than expected /desired or if the tissues keep stretching over time.
Judging how the patient’s tissues will respond to the forces at play during and after breast augmentation surgery is a little like the winter Olympic sport “curling.” In curling, the heavy stone is put in motion and then slides along the ice. In an effort to achieve a perfect landing, other players can modify the path slightly by sweeping with brooms ahead of the stone. However, there are many variables, including ice texture and temperature.
The surgeon makes a space for the implant, putting the implant in “motion” and estimating how the tissue in the lower half of the breast will stretch after the operation. The stretching may be helped for a few weeks after surgery using a breast stabilization strap (push-down strap) on the upper breast to encourage settling lower. Alternately, a brassiere can be used to slow the descent and lessen the stretching. Both of these should be at the direction of the surgeon and can be overdone, but they can modify the outcome to a significant extent (much like the sweepers in curling). Most of the time, the implant settles just right, and all looks great. However, if the tissues stretch more than expected, the implant can settle too low and “bottom out.”
Other factors include:
- Amount of muscle release with submuscular implant
- Implant size/weight compared to the quality of supporting tissues
- How slender the patient is
- Breast tissue volume before the operation
Implant Malposition and Other Implant Displacement Problems
Although “bottoming out” or inferior displacement is the most common displacement, implants can become displaced in any direction (laterally, medially, and less often superiorly) and often do so in an asymmetrical fashion.
Lateral displacement occurs when implants slide too far to the side when standing or lying. This displacement may cause an unusual and unnatural appearance of the breast or nipple/areola complex and/or leave a large gap between the breasts. Lateral displacement may be treated by capsulorrhaphy with or without ACD reinforcement. Sometimes implants under the muscle need to be brought out in front of the muscle.
Medial Displacement (Symmastia)
Symmastia, also called “uni-boob” or “bread loafing”, appears when the implant displaces medially, and the breasts appear to connect in the middle of the chest). This can be just the skin tenting anteriorly away from the breastplate (sternum), or it can be an actual connection across the middle between the breast implant pockets. Symmastia may be treated by capsulorrhaphy with ACD reinforcement. Sometimes implants over the muscle need to placed under the muscle.
Superior Displacement (Implants Settle Too High)
Implants can remain too high if they don’t settle enough or fail to stretch out the lower breast as much as expected. Surgery can be relatively simple: capsulotomies or lower capsulectomy to allow the implant to settle. However, it is important to diagnose the cause of the too high implant, or this simple surgery will not work. If caused by a surgeon trying to augment a drooping breast without a needed lift, a double bubble deformity may develop unless a breast lift is performed. If caused by capsular contracture, extra steps for capsular contracture surgery will be needed to avoid reoccurrence.
This procedure tightens the implant pocket. This tightened pocket may also need reinforcement with ACD (“acellular dermis”) to best maintain the improved look.
Sometimes, other procedures are needed, including:
- Combinations of breast lift/ breast reduction with larger implants
- Neo-pocket creation
- Change from/to subglandular/submuscular location.
The implant size, nature, and projection can be revisited to best achieve the desired outcome.
Recovery depends on the extent of the procedure necessary for correction. If only a capsulorrhaphy is needed, there will be much less discomfort that the original breast augmentation surgery, and a weekend may be all that is necessary for recovery. The more techniques that are needed to achieve the desired look will lengthen the recovery by a few days to a week before the patient may increase her activity. A special supportive bra created by Dr. Pertsch may be needed for up to six weeks. Upper arm activity is often limited for upwards of six weeks to allow for adequate healing and avoid reoccurrence.