Breast augmentation mammoplasty, breast lift mastopexy, breast revision, and any breast procedure involves risk. There are numerous post-operative complications that may occur after breast surgery, and while rare, it is important to understand them fully. Among the few potential complications that can arise after breast implant surgery, implant displacement, or “bottoming-out,” is one of the more common issues. This is particularly because it can happen in both the short and long term. While it is still a rare complication, the instance of bottoming-out has increased in recent years. This increase comes alongside a few industry trends.

Firstly, breast augmentation mammoplasty has increased in popularity across all demographics, including women with children, and older women. As such, there is a greater number of women with breast ptosis, poor skin integrity, and those who require a breast mastopexy or augmentation mammoplasty surgery. Secondly, there is an increased trend towards a more enhanced aesthetic, which goes hand-in-hand with larger implant sizes. This can have a significant impact on long-term results as you will learn in this blog post. So what is bottoming-out after breast augmentation mammoplasty, what causes it, who is more prone to bottoming-out of implants, and how do we fix it? This blog post aims to answer all of these questions to help women considering breast surgery.

What is implant bottoming out?

Bottoming-out is an uncommon complication that involves displacement of the breast implant below the breast fold (also known as the inframammary fold), or downward displacement of the implant in relation to the nipple position. There is an important distinction to be made here between natural breast ptosis and bottoming-out. Patients with a bottomed-out implant will see that the implant has descended below its original position. As a result, there is a disproportionate amount of lower-pole fullness. The nipple will appear unusually high, or pointing upwards, signalling that the implant has moved. Natural breast ptosis will occur due to natural ageing where there is gradual and proportionate drop of the breast, nipple, and implants. You may lose upper-pole fullness, or your breasts may stretch. This is not an indication of a bottomed-out implant. The following image illustrates this concept:

You should always organise a review with your plastic surgeon before jumping to any conclusions. This is because bottoming out is very commonly mistaken for natural breast ptosis.

What causes bottoming out?

Bottoming out of implants is caused by a number of different, and sometimes interrelated factors. 

Skin integrity

Patients with poor skin integrity are more prone to bottoming-out. Limited skin elasticity, natural breast ptosis or laxity, breast lift mastopexy patients, and women who have breastfed are all examples of patients that are likely to have poor skin integrity, and may be at a higher risk. This increased risk is due to the inability of the breast skin to support the weight of the breast implants. The implant places downward pressure on the lower-pole of the breast. While some patients’ skin will support the implant in its desired position, a patient with poor skin integrity may experience the implant descending downward due to the lack of support. This can reach the point of bottoming-out if the patient is not providing the appropriate support to the lower pole of the breast.

Implant Size

Implant size plays a significant role in preventing and causing bottoming out. A higher implant CC equates to a heavier implant. A heavier implant equates to greater downward pressure on the lower pole of the breast. As such, a heavier implant will increase the chances of bottoming-out. 

Implant Shell 

In recent years with the identified risk of BIA-ALCL associated with textured implants, there has been an obvious shift away from textured implants for patient safety. In the past, plastic surgeons preferred textured implants. This is due to their grip within the breast pocket which creates increased stability and reduced risk of displacement. By contrast, the smooth-surface implants are more prone to movement and as a result, more prone to bottoming-out. Due to the risks associated with textured implants, this is a reality that must be accepted. Thankfully, new generation implants such as Motiva Implants feature a smooth implant with a “nano-textured” surface, which is the best of both worlds. These implants don’t completely eliminate risk, but they do provide a level of increased stability, with no recorded risk of BIA-ALCL. Motiva implants are Dr. Philip Richardson’s breast implant of choice due to their safety profile and ability to overcome some of the limitations associated with traditional smooth implants.

Implant Placement

Implant placement also plays a key role in the risk of breast implant bottoming-out. Over-the-muscle placement of implant can increase the risk of implant bottoming-out. This is because the implant is only supported by the breast skin and tissue. This is as opposed to being supported by the pectoralis muscle. In contrast, a sub muscular placement will include muscle coverage. This will help provide internal support to the breast implant and reduce downward pressure on the breast skin. 

Support

A huge factor in the risk of bottoming-out is the level of post-operative support placed on the breasts both in the short and long-term. Wearing a supportive bra is a key aspect of prevention. The supportive garment will help to hold the implant in its desired position, and prevent the lower pole from descending. Wearing a supportive bra in the post-operative phase—particularly in the first year—will also allow for appropriate formation of scar tissue. Scar tissue around the implant will act as an internal support for the implant. This is a huge factor in maintaining results and preventing displacement, mainly for those patients with poor skin integrity or who are at a higher risk of bottoming-out.

Who is more prone to implant bottoming out? 

Mothers

Mothers, particularly those who have breast-fed, are at a higher risk of implant descent. This is due to the significant changes to the breasts during pregnancy and birth, and the subsequent loss of elasticity. Of course, not all mothers will see a huge impact on skin integrity following children, but many do. The best way to find out your risk factor for bottoming-out is to discuss this with your plastic surgeon.

Mastopexy Patients

Generally patients who require a breast lift (mastopexy) have breast ptosis and/or significant loose breast skin. As such, the integrity of the skin is generally low, and patients who have a mastopexy and augmentation mammoplasty (lift with implant) at the same time are at a high risk of bottoming-out because of this. In these cases to prevent the complication, surgeons will recommend a two stage procedure. This is where mastopexy surgery is performed first, and augmentation mammoplasty surgery is performed a number of months after. The rationale behind this is that the breasts have time to heal and adjust, for a stronger foundation for the implants. In addition, the surgeon will recommend a small implant to further reduce downward pressure.

Hobbies and Activities

Lower pole strain can be a result of many different activities, including but not limited to jumping, running, and horse riding. These activities can cause the implants to push down on the lower pole and displace. It is important if you are engaging in any of these activities that cause excessive bounce or movement of the breasts, that you use strong supportive bras to mitigate the risk of bottoming-out over time. 

Understanding the risk factors associated with implant displacement is important and should be considered when weighing the risks and benefits of the procedure. In order to provide appropriate support for the breasts as much as possible, you should trust your surgeon’s recommendations. But what if you already have bottoming-out (displacement)? What are the treatment options?

How do we fix implant displacement?

Thankfully bottoming-out is not a permanent complication, and there are a number of surgical techniques available to revise the issue. 

Internal Bra to prevent implant bottoming out

The most common treatment for implant bottoming-out is through the use of an internal bra. An internal bra involves reinforcing the lower pole of the breast through the use of sutures along the inframammary fold to secure the implant in place. In more rare cases, surgeons may use a mesh product to reinforce the lower pole further. Plastic surgeons such as Dr. Philip Richardson use the internal bra technique as a standard measure for risk patients to prevent bottoming-out. Internal bra can also be an effective revisional technique to reposition and secure the breast implant. Your surgeon will advise post-operatively the importance of supporting the breasts with the post-operative compression bra for as long and as often as possible for the first year following surgery to ensure the formation of scar tissue around the implant for further support.

Smaller Implant to prevent implant bottoming out

In some cases, an internal bra and implant exchange are combined. This is generally using smaller implants. Patients with large implants may be advised to downsize to avoid implant descent. This is because the smaller implant can maintain its higher position. 

In more complex cases, your plastic surgeon may recommend additional revisional techniques to achieve the desired outcome. You may benefit from seeking a second opinion from a fully-qualified plastic surgeon in these circumstances to fully understand all the options available to you and make a more informed decision.

To conclude

In this blog post, we have reviewed the issue of bottoming-out after breast augmentation mammoplasty surgery. If you feel your breast implants may have bottomed-out or become otherwise displaced, or you require revisional surgery to revise a complication, contact our rooms today to schedule a consultation with Brisbane’s breast surgeon.