As a plastic surgeon with extensive experience in breast augmentation procedures, I’ve seen firsthand how breast implant positioning can make or break aesthetic outcomes.
One of the most common revisional breast surgeries we perform at Blackhawk Plastic Surgery stems from a single issue: implants placed too low without a necessary lift.
The natural history of improperly positioned implants is predictable – they tend to slide downward and outward over time.
Understanding the Problem
When evaluating a patient for breast augmentation, proper positioning of the implant on the chest wall is absolutely critical. If a patient has drooping breast tissue and the nipple sits at or below the inframammary fold, an implant alone isn’t sufficient. A lift becomes necessary to reposition the breast tissue properly over the implant.
What many don’t realize is the consequence of cutting the chest muscle during some augmentation techniques. When the muscle is cut, it slides upward while the implant rests on the bottom of the breast tissue – essentially placing weight in an area that’s already compromised.
Some surgeons anticipate this problem but employ questionable solutions.
I’ve seen cases where the inframammary incision was deliberately placed below the natural fold because the surgeon knew the fold would descend after surgery. However, this approach often leads to further complications.
The “Bottoming Out” Phenomenon
Within months after such procedures, patients notice continuing descent of their implants, with incisions riding up onto the breast instead of staying hidden in the fold. The increasing space between the new lowered fold and the scar creates what we call “bottoming out” – implants that keep sliding downward.
This malposition follows an upside-down “V” pattern. As implants descend, they also move outward, creating wider separation between the breasts and diminishing cleavage.
Patient Tissue Composition Makes a Difference
I’ve observed significant variations in tissue strength among patients. During surgery, I evaluate each patient’s connective tissue – the fibrous structural framework of muscles and soft tissues. This assessment helps determine optimal pocket creation.
For patients with extremely firm tissue, I create the exact pocket shape needed, knowing it won’t change much over time. With average tissue strength, I make the pocket slightly narrower than desired, anticipating some stretch during healing. For patients with very soft tissue, I make pockets significantly narrower and higher to compensate for the inevitable expansion.
When a patient with soft tissue undergoes a procedure where the chest muscle is cut, the risk of implant descent is substantially higher.
The Visual Impact of Bottoming Out
The aesthetic consequences of bottoming out are significant. As implants descend, the nipples appear to rotate upward, creating an awkward look. Often you can see a visible crease where the natural fold should be, with a substantial portion of the implant sitting below this point.
Some cases resemble a sock with a rock inside – the implant creates a bulge that moves outward and downward rather than maintaining a natural breast contour.
Correcting the Problem
Revisional surgery for this condition typically involves a capsulorrhaphy – a technique where we excise the old scar and repair the inside of the capsule, recreating it higher on the chest wall closer to the natural fold position. This is paired with new implant placement.
The results are dramatic.
After correction, patients enjoy better cleavage with implants positioned closer together and higher on the chest. The scars return to their proper hidden position in the fold.
Additionally, we effectively “return” skin that had crept up from the abdomen, creating a taller abdomen appearance which visually narrows the waist.
Prevention is Better Than Correction
The best approach is prevention. By maintaining the chest muscle intact and properly positioning implants from the start, these complications can be avoided entirely. For patients with existing drooping tissue, combining augmentation with a lift from the beginning delivers superior long-term results.
This is why I carefully assess each patient’s tissue characteristics and make pocket dimensions specific to their needs. The goal is always a proportional, natural-looking result that maintains its position over time.
The Timing of Revision
For patients unhappy with recent augmentation results, patience is key. While serious complications like infection require immediate attention, most aesthetic concerns should be evaluated after complete healing – typically waiting a full year before considering revision.
Looking Forward: Beautiful Results That Last
Proper breast implant positioning remains one of the fundamental principles in achieving excellent breast augmentation outcomes.
When combined with appropriate lift procedures for patients who need them, and careful attention to individual tissue characteristics, we can create beautiful, long-lasting results.
For patients experiencing bottoming out after previous surgery, take heart. This is one of our most common revisional procedures, and the correction typically delivers dramatic improvement in breast shape, cleavage, and overall body proportions.
