Breast augmentation is a common procedure, but it carries the risk of long-term complications that can affect the final appearance. One such issue is breast implant bottoming out, a specific complication that compromises the intended aesthetic outcome. This article explores what this condition is and details the measures taken both surgically and post-operatively to prevent it.
Understanding Bottoming Out: Definition and Identification
Bottoming out refers to the downward displacement of the breast implant, causing it to drop below the inframammary fold (the natural crease beneath the breast). This complication arises when the soft tissue of the lower breast pole, which supports the implant, stretches or weakens over time. The result is an imbalance in breast volume, with the lower half appearing overly full or elongated compared to the upper half.
Patients can identify this issue by looking for specific visual cues. A common sign is the nipple-areola complex appearing unnaturally high on the breast mound or pointing slightly upward. The distance between the nipple and the inframammary fold will appear noticeably stretched. In some cases, the implant sitting too low can create a “double bubble” appearance, where the implant and the natural breast tissue form two distinct contours.
Factors That Increase Risk
The likelihood of an implant bottoming out is influenced by the patient’s existing anatomy and the surgical choices made. Pre-existing conditions such as poor skin elasticity or thin native breast tissue offer less natural support for the implant. If a patient has pre-existing ptosis, or sagging, the weakened tissue is less capable of holding the implant in a stable, elevated position.
Implant selection also plays a significant role. Choosing implants that are excessively large or heavy relative to the patient’s frame increases the gravitational strain on the lower pole tissue. This continuous weight can hasten the stretching of the inframammary fold, causing the implant to descend. Tissue integrity is also compromised by significant weight fluctuations, aging, or hormonal changes, which can lead to a loss of skin collagen.
Surgical Techniques for Prevention
Prevention begins with the surgeon’s execution and planning during the operation to create a stable environment for the implant. The initial step involves meticulously dissecting the implant pocket to the exact size and position required, avoiding over-dissection that would allow the implant too much room to migrate downward. The correct placement of the inframammary fold is secured using specialized internal sutures, known as inframammary fold suspension sutures, which anchor the lower breast tissue to the chest wall.
Surgeons often prefer submuscular placement, positioning the implant partly beneath the pectoral muscle. This provides a supportive layer of tissue over the top of the implant, helping prevent it from slipping.
Internal Bra Technique
For patients with higher risk factors, such as very thin tissue or a large implant size, a technique known as the “internal bra” may be used. This involves reinforcing the lower pole with supportive biological materials, like acellular dermal matrix, or a synthetic mesh. These materials act as a scaffold to provide stability and prevent tissue stretching.
Post-Operative Prevention and Care
The patient’s adherence to the post-operative care plan is important in preventing bottoming out. Immediately following the procedure, the consistent use of specialized support bras and compression garments is mandatory. These garments hold the implant in its surgically determined position and minimize movement while the internal tissues heal and scar tissue forms a supportive capsule around the implant.
In some cases, the surgeon may prescribe an inframammary stabilizing band, which is worn above the implant to exert downward pressure on the upper pole. This encourages the implant to settle correctly and prevents it from migrating too low. Restrictions on physical activity are strictly enforced, particularly avoiding upper body exertion, heavy lifting, or strenuous exercise that could strain the healing surgical pocket. This period of restricted movement allows the lower pole tissue to strengthen and the internal scar to mature, securing the implant in its final position.