Revision Surgery
Bottoming Out After Breast Augmentation
“Only the lower breast bulges and the upper looks empty” — some come with this some time after surgery. It is called bottoming out. To answer first: bottoming out is the implant alone dropping. The nipple stays in place while the fold descends with the implant, so the shape looks off. This article settles the problem of the implant leaving its position: why it happens, how it differs from ptosis, how to prevent and correct it, how to tell it from a double bubble, and how the four malpositions are diagnosed and when they are repaired. Every clinical figure is linked to a cited study.
1. The condition called bottoming out
Distinguishing bottoming out from ptosis matters because the correction differs. Bottoming out is the implant descending below its original position. The nipple then sits relatively high, and the lower breast becomes excessively convex. The characteristic is the inframammary fold (IMF) descending below where it was, so the shape looks awkward — simply put, the implant has been pushed down by gravity. It starts as a small change but can worsen over time: the upper breast looks empty and only the lower is convex, and it can be uncomfortable even under clothing.
2. The four causes
- Over-dissecting the pocket during surgery: opening the lower part too much when making the space gives the implant room to drop, and a weakened lower border lets gravity move it down slowly.
- An implant too large for the frame: a heavy implant is affected more by gravity, so tissue cannot bear the weight and it gradually migrates downward over time. Matching size to the base width is the basis (Tebbetts & Adams, Plastic and Reconstructive Surgery, 2005).[2]
- Poor skin elasticity: with elasticity reduced by childbirth or aging, bottoming out is more likely, because the skin and soft tissue support the implant less.
- Subglandular placement: compared with under the muscle, placing under the gland gives weaker support — without the muscle as a natural support, the implant moves down more easily.
3. Bottoming out versus ptosis
Many confuse bottoming out with ptosis, but they are strictly different.
- Ptosis: skin and glandular tissue descending together — the nipple and gland droop together.
- Bottoming out: the implant alone moving down — the nipple stays in place while the implant drops, so the nipple points upward.
This distinction matters because the treatment differs: ptosis needs nipple-position correction, bottoming out needs pocket reinforcement. Accurate diagnosis comes first.
4. Preventing bottoming out
The most important thing in prevention is conservative pocket dissection — setting the IMF accurately and not doing unnecessary lower dissection.
- Choosing an appropriate implant size: an oversized implant raises the risk; a size matched to the frame matters.
- Using the dual plane technique: the muscle holding the upper implant can prevent downward migration to a degree (Tebbetts, Plastic and Reconstructive Surgery, 2001).[1]
- Early stability after surgery: a strong impact before the implant settles can change its position, so avoid vigorous exercise for 4–6 weeks after surgery.
Asking specifically about the IMF-setting method and the extent of pocket dissection at consultation helps.
5. Correcting bottoming out
Once bottoming out is confirmed, correction is needed. The representative methods:
- Capsulorrhaphy: suturing the capsule at the descended fold so the implant cannot drop further — narrowing the lower part of the pocket the implant sits in.
- Mesh reinforcement: in severe cases, fixing a biocompatible mesh at the fold to reinforce it structurally.
- Implant-size adjustment: reducing the implant size while correcting, in some cases.
The most important thing in correction is approaching after identifying the cause accurately. Revising by the same method can produce bottoming out again, so responding to the cause is the key to preventing recurrence. Because bottoming out worsens over time, early detection and early correction matter — visit the operating clinic promptly when a change is felt.
6. Distinguishing from a double bubble
What is often confused with bottoming out is a double bubble. Both are changes in the lower breast, so they come up together in consultation, but the cause and correction differ.
- Bottoming out: the implant drops below the fold so the nipple-to-fold distance lengthens; only the lower part bulges and the nipple points up.
- Double bubble: the old fold remains as a horizontal line above the dropped implant, so two lines show — it arises because the structure of skin and fascia attached at the old fold remains.
The two can coexist, so ultrasound is used to look at the implant position and fold state together.
7. The four implant malpositions
Bottoming out is in fact one within the larger category of malposition. It is not very common, but when it occurs it is among the things that do not improve on their own.
| Type | How it looks |
|---|---|
| Bottoming out | The implant drops below the fold so the nipple looks relatively high |
| Double bubble | The old and new folds show together |
| Lateral displacement | The implant falls to the side; lying down, it flows outward |
| Rotation | A shaped (teardrop) implant turns so the shape distorts |
The causes generally overlap: an implant larger than the breast base width, tissue weakened by childbirth or weight change, an over-dissected fold, and an abnormally formed capsule. It usually appears gradually between 6 months and a year after surgery — not suddenly one day, but progressing little by little. Diagnosis can be suspected by eye, but the post-op photo and the current photo are set side by side to compare the fold and nipple positions, and ultrasound confirms the implant position and capsule state, with MRI if unclear. A mild case can be watched with a support garment and posture care, but a clear malposition does not improve on its own; if it continues past 6 months, revision is discussed. Revision has a slightly higher recurrence risk than the first surgery. And correction is not just changing the implant — suturing a new fold from inside and tightening the capsule to remake the pocket itself is the key, with size or plane changed too if needed. Leaving the cause and only swapping the implant repeats the same thing.
Summary
- Bottoming out and ptosis are different. Bottoming out is the implant alone dropping so the nipple points relatively upward; ptosis is skin and gland descending together. The correction differs, so distinguishing comes first. A double bubble, where the old fold remains as a line, is a separate problem.
- The cause is mostly the pocket and size. Over-dissecting the lower part or placing an implant large for the frame is most common, with reduced skin elasticity and weak support overlapping. It usually appears gradually between 6 months and a year.
- Correction starts after identifying the cause. Narrow the lower border with a capsulorrhaphy or reinforce with mesh, reducing the implant size too if needed. Doing it again under the same conditions recurs.
References
- Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types. Plast Reconstr Surg. 2001;107(5):1255–1272. doi:10.1097/00006534-200104150-00027.
- Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process. Plast Reconstr Surg. 2005;116(7):2005–2016. doi:10.1097/01.prs.0000191163.19379.63.
Medical disclaimer. This article is general information and does not constitute medical diagnosis or treatment advice. Results vary with individual tissue condition and body type; accurate diagnosis and surgical planning are determined through in-person consultation with a board-certified plastic surgeon.
Dr. Kim Uigeon (Board-certified plastic surgeon, Republic of Korea · UNE Plastic Surgery)