Bottoming Out Implants

  • Bottoming Out / Breast Fold Malposition Overview
  • Etiology of Bottoming Out / Breast Fold Mal-position
  • Procedure Walk-Through
  • Bottoming Out / Breast Fold Mal-position FAQs

Breast Fold Malposition Overview

Breast fold mal-position and a variant, referred to as bottoming out are conditions which can occur to breasts which have undergone breast enhancement or mastopexy ( breast lift ) with implant placement. In these conditions, the fold may be disrupted and subsequently displaced inferiorly ( this is referred to as “bottoming out”) or in more rare instances, laterally, requiring breast revision surgical correction to regain natural breast shape and proper symmetric position.


Figure – Breast fold disruption can occur medially and inferiorly


The shape and boundaries of the breasts are clearly defined in their natural state by anatomic landmarks which delineate the breast mound from surrounding tissue and give the breasts their natural, beautiful curves and lines.  Inferiorly, the breast fold or “infra-mammary fold” serves as a structural component, helping maintain the lower pole position.  In certain circumstances, the fold, either inferiorly, or on the sides, can be disrupted, causing bottoming out or lateral fold mal-positioning – this can occur for a number of reasons, as discussed below:


Figure – Implementation of Strattice™ to help in IMF recreation

In traditional breast enhancement and breast rejuvenation surgeries, such as a breast augmentation, for example, the implant pocket is developed, either under the muscle ( sub-muscular ) or breast tissue ( sub-glandular ).  As discussed above, the anatomic landmarks of the breast are pre-determined in the body and help define the native breast shape.  In rare instances, these anatomic landmarks may be disrupted –  either due to overzealous implant pocket dissection during the surgery or due to occult intrinsic weakness in the breast tissue which is only realized during surgery or after surgery. There are several factors which may contribute to weakness of the breast tissue lending to fold disruption.  Some of the more common include aging, significant weight gain followed by weight loss, pregnancy, multiple breast surgeries, and hereditary factors.

One important factor to keep in mind, which is often overlooked during consultations is implant size:  The larger the implant, the greater the weight imparted on the breast tissue.

Studies have demonstrated that implants larger than 500 ccs are more likely to bottom out – and it is worth noting that this can be secondary to two factors:

  • Implant fold disruption –  as discussed above

Stretching, secondary to a loss of skin elasticity of the native breast soft-tissue will act to increase the nipple-to-fold distance over time, creating a breast mound distortion, with the nipple appearing to sit “higher” than would be expected with the skin beneath it appearing disproportionately excessive in regards to relation of the overall breast. This is demonstrated in the illustrations above and directly below:


Figure – Descent of the breast seen in “ bottoming out “



Procedure Walk-Through


When a diagnosis of bottoming out or breast fold disruption is established, the typical course of treatment is to re-create the fold through breast revision surgery – this is accomplished by various means, depending on the native problem. Options for correction of fold disruption include, but are not limited to:


  • Capsulorrhaphy – Here, the internal lining, or breast capsule, is re-approximated to itself, to re-create a natural, more anatomic breast contour.  This procedure is typically is typically performed in conjunction with other adjuvant procedures, as discussed below.


Figure – Capsulorrhapy with implementation of Strattice


  • Internal bolstering –  This is a technique employees the re-creating the natural breast fold through the used of permanent sutures which are traditionally approximated to the underlying ribs.
  • Strattice™ Reconstructive Tissue Matrix –  in cases where additional support is required to recreate the breast fold, a tissue matrix, such as Strattice, may be utilized.  The product is derived from a porcine origin, is sterile, and incredibly strong and flexible. During surgery, Strattice may be attached to the chest muscle and to the existing fold to lend support and create a more anatomic breast shape and thus positioning the breast more ideally.

     Fold recreation with use of Strattice Tissue Matrix



Infra-Mammary Fold Disruption & Bottoming Out FAQs


Who should undergo surgery to repair bottoming out or breast fold disruption ?

Patients who have incurred or developed breast bottoming out secondary to breast enhancement or combination breast procedure such as an augmentation-mastopexy are candidates for fold disruption surgical repair.

What is the timeline to schedule breast revision surgery ?

In general, ample time from the initial surgery to the time of repair is recommended prior to undergoing IMF repair or related procedures. If the initial breast surgery has occurred at least 12 months prior to the development of the IMF disruption, the breast capsule, at this stage, will typically be well delineated, allowing for surgical repair. Attempts to repair the fold any earlier than this may increase the risk of recurrence.  In some instances, Dr. Vallecillos may elect to perform the procedure sooner – but this is based on a case to case basis.

What are the benefits of surgery to repair bottoming out or IMF disruption ?

The primary benefit of the surgery is to regain the natural contour and correct positioning of the breast on the chest wall.

What are the typical incisions used to correct IMF disruption ?

The surgical correction is generally performed through the initial surgical incision, although not in all instances. Dr. Vallecillos will best determine where the incision should be made to ensure the greatest chance of a successful corrective surgery.

Can surgery to repair bottoming out or IMF disruption be avoided?

Repair of IMF disruption or related problems is purely an elective surgery and thus an elective decision –  Dr. Vallecillos will discuss if and when the surgery should be planned, if at all.

What is the typical recovery from breast fold disruption repair surgery ?

Recovery from breast fold disruption surgery can take longer than traditional breast surgeries because an extensive time is required for optimal healing.  In general, the patient must refrain from lifting greater than 10 lbs or upper body exercise for no less than 8 weeks –  this will allow for maximal “take” of the repair, increasing the chances of a successful outcome.

Why choose Dr. Vallecillos to repair bottoming out or IMF disruption surgery ?

Dr. Vallecillos is a Beverly Hills board certified plastic surgeon with a practice focus on breast revision surgery, including breast fold disruption surgery. Call our offices today to schedule a consultation with Dr. Vallecillos and he will provide you with surgical options.


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