Background: The placement of breast implants is largely debated about whether it should be above or below the pectoralis muscle. While this is an extremely important decision, the implant’s relationship to the inframammary fold also has relevance. It will have an influence on how the augmented breast shape will look, regardless of the tissue plane location of the implant.
The inframammary fold (IMF) is a definitive attachment of the underside of the skin to the deeper tissues along the ribs. It is a well-described set of ligamentous attachments that make for a distinct transition between the breast and the abdomen. In some cases of breast augmentation, the IMF is maintained wile it others it may be necessary to lower it to accommodate the implant size and to expand out the lower pole breast skin. Detaching the IMF always has a risk that as the implant settles and the swelling subsides it will drop down too low below the center of the breast mound.
When a breast implant drops down below the established or released inframammary fold, it is known an implant bottoming out. It is obvious to an observer as an implant bulge on the bottom of the breast. It is most obvious to the patient as a lack of adequate upper pole fullness. The implant may cause some persistent discomfort as it pushes downward onto the abdominal tissues and can make it difficult to wear bras comfortably. Depending upon how much the implant has dropped will determine what surgical technique is needed to fix it.
Case Study: This 40 year-old female presented with bottoming out of both of her breast implants. Her history was that she had a combined full breast lift with submuscular silicone implants placed over one year ago. Within weeks after surgery her breast implants ‘fell’ and were too low, worse on her left side than her right. A revision to reposition her implants was done at four and seven months after her original surgery but both efforts resulted in the implants falling back down with no significant improvement.
She was taken to surgery where an inframammary approach was used to expose both implants. The capsules were opened, the lower portions of them removed and permanent sutures were used to tighten the capsules up and back down from a 3:00 to 9:00 position on both breasts. The dermis on both sides of the incisions was then sewn down to the deeper tissues to make for very well-defined inframammary folds across the base of the breasts. No drains or other special supportive dressings were at the conclusion of the procedure.
She was allowed to wear an underwire bra after surgery. She returned to working out at 6 weeks from the procedure but no strenuous arm motions were allowed. When seen at 4 months after surgery, her implants remained in good position. They remained slightly high as desired with no lateral shifting of the implants and full upper pole fullness.
Correction of breast implant bottoming out can be done by several techniques based on the severity and recurrence of the problem. Initial efforts should be done using capsulorraphy techniques using permanent sutures. Failure of sustained implant repositioning may be technically related based on the quality of the tissues and the ability to get good fixation of the sutures. If this approach fails the use of allogeneic dermal grafts placed as suspension slings may be needed.
Case Highlights:
1) Bottoming out of breast implants occurs when there is disruption of the inframammary fold attachments. It can occur in any procedure which involves the placement of an implant.
2) Repositioning and resuspension of the implants back up onto the chest wall requires re-establishment of the inframammary fold through a variety of techniques.
3) The stability of breast implant positioning after a bottoming out repair can not be determined for a minimum of three to six months after surgery.
Dr. Barry Eppley
Indianapolis, Indiana