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Bottoming Out

Bottoming out on patients is seen all the time by Dr. Linder in his Beverly Hills/Hollywood as well as Las Vegas breast practice. Patients can be seen for bottoming out for many reasons. One reason is malposition of the implants. Simply, the implants are placed too low by the plastic surgeon right off the bat. This is the worst scenario, in that these inframammary folds have now been completely released, opened and the implants have now fallen quite early, right after surgery. Other reasons simply include the patients do not wear underwire brassieres and over years the weight of the implants causes gravitational descent of the tissue which may cause dehiscence of the inframammary fold where the implants ends up low and the nipple ends up at the top of the breast. Unlike implants that are too high, implants that are too low are more difficult to correct because the inframammary fold is lowered. Elevation of the inframammary fold will require either a capsulorraphy where the internal sutures are made to repair the internal capsule and elevate the inframammary fold. The problem with that is the sutures often do not hold, the inframammary fold can become square-looking or there are very high rates of recurrence of the inframammary fold lowering. Other possible ways to repair the skin include inframammary tightening procedure where skin is removed along the inframammary fold and tightened/sutured upward and elevated. This can work; however, it may require a formal mastopexy, removing skin around the areola vertical limb and along the inframammary fold to more greatly improve the results.

before and after bottoming out correction 1 of 2

Patients who present with bottoming out may also do better with a smaller implant placed in order to reduce weight and thereby recurrence of the bottoming out of the breast. Very large saline and silicone implants can certainly cause the muscle to dehisce, spread, stretch and the inframammary fold to loosen, as well as to dehisce and thereby allow downward descent of the inframammary fold. Women who have had multiple children and breast fed may also have poor strength to the inframammary fold fibers of the pectoralis major fascia which may also cause the implant to bottom out even if the implant was properly placed and the fold was not lowered improperly.

before and after bottoming out correction 2 of 2

Our patients are made to wear sports bras at night forever and an underwire regular bra forever, once they have completely healed from surgery, in order to maintain the implant position and prevent the weight of the implants from pulling the skin and tissue downward.

Only Board Certified Plastic and Reconstructive Surgeons should be performing secondary revisions on bottoming out of patients' breast implants due to the difficulty of this operation. Bottoming out is certainly one of the most difficult surgeries in the breast revision forum in order to repair due to the difficulty of maintaining the inframammary fold superiorly.

Another approach to fix bottoming out is complete explantation of the implants, allow the tissue to tighten over six months to one year, then reimplantation of the implants in new pockets. It could be going from a subglandular to subpectoral or subpectoral to a new pocket above the muscle subglandular. However, as discussed previously, subglandular pockets have an increased risk of scar tissue hardening, and capsular contracture which may be another problem in itself.

We see patients in Beverly Hills and Las Vegas weekly who require breast revision surgeries, including bottoming out of the breasts due to:

1) implants placed that are too large
2) malposition of the implants with the inframammary fold release too low
3) patients' inability to maintain the inframammary fold position due to inadequate support (i.e., underwire brassieres postoperatively).

Bottoming out can certainly be prevented in a significant number of cases simply by the patient wearing supportive brassieres the rest of her life and athletic brassieres at night to maintain position of the implants as well.

Dr. Linder welcomes patients throughout the country and world for repair of this difficult problem.

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Dr. Linder is a Breast Revision Specialist Dr. Stuart Linder

Stuart Linder, M.D., F.A.C.S. is a Beverly Hills and Las Vegas Breast Revision Surgeon who enjoys performing breast augmentations, breast revisions, breast lifts, breast reductions and breast reconstructive surgery. He is a Diplomate of the American Board of Plastic Surgery and a Fellow of the American College of Surgeons and a Member of the American Society of Plastic Surgeons.

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Stuart A. Linder, M.D., F.A.C.S. Las Vegas Breast Revision Specialist
9167 W Flamingo Rd, Suite # 110, Las Vegas, NV 89147
Phone: (702) 434-7205
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