When the breast shape changes from the original result after augmentation, or the implant sits too low and the inframammary fold collapses, this is called bottoming out. It differs from simple sagging: the position and size of the pocket created for the implant, and the support of the inframammary fold, all play a part. In particular, dissecting the implant pocket further down than necessary lowers the fold and changes the relative position of the nipple. Breast augmentation is therefore not only about choosing implant size and shape — creating the pocket accurately for your breast structure matters just as much.
Contents
What is bottoming out?
Bottoming out is the implant moving lower than planned, deforming the lower breast contour and the inframammary fold. The fold descends and the nipple appears to point relatively upwards, or the implant concentrates below the nipple so the breast looks elongated. A prominent lower implant edge is also characteristic.
Ordinary sagging centres on skin and glandular tissue descending, while bottoming out occurs as the space supporting the implant and the structure of the fold change. The two can occur together, but their causes and corrections differ. Not every breast that looks longer is bottoming out: nipple position, the inframammary fold and implant position should be assessed together.
Why does it happen?
Excessive inferior dissection. Dissection is the process of separating tissue to create the implant pocket. If dissection extends below the tissue supporting the inframammary fold, the implant can sit lower than planned. Creating the pocket lower than necessary can weaken or move the existing fold, so the planned fold and the actual dissection should match.
Weakened fold support. The inframammary fold is a structure where skin and fibrous tissue connect to maintain the lower border of the breast. If support there weakens or is damaged during surgery, the implant is more likely to move down. Preserving the tissue that maintains the fold matters as much as creating space.
Implant size and weight. A larger implant increases the load on breast tissue. Inserting a heavy implant that is large relative to breast width or tissue support adds strain to the fold. Size should be chosen with chest width, existing tissue and skin support in mind, not only the desired volume.
Skin and tissue condition. Where skin is thin or has lost elasticity, breast tissue is minimal, or sagging already exists, support may be insufficient. Pregnancy, childbirth, weight change and ageing alter skin and tissue shape. Assessing the tissue that will support the implant before surgery helps reduce the chance of long-term positional change.
In a study combining anatomical study of the inframammary fold with clinical outcomes, bottoming out occurred in 6% initially but was prevented after the dissection technique was changed to preserve the fold's supporting structures.[1]
Read alsoCapsular contracture and rippling are covered in “When the breast hardens, and when waves show” (Korean).
Why must the implant pocket be precise?
The pocket determines implant position and breast contour. If it is too wide or created too low, the implant can leave the planned position; if it is too small, the implant cannot sit where intended and unnecessary pressure is applied to surrounding tissue. The point is not to make a large pocket but to make exactly the space the implant and breast tissue need.
Designing the pocket considers breast width, fold height, nipple position, tissue thickness and elasticity. Preserving the supporting structure around the fold and forming a boundary that keeps the implant from being pushed down are important. Endoscopic techniques can help visualise internal tissue and the extent of dissection, and precise dissection reduces unnecessary tissue damage.
Implant size, pocket size and fold support are linked. Choosing an implant size without adequate pocket design can lead to positional change or asymmetry after surgery. Analysing breast structure and planning the implant and pocket together helps maintain a natural contour and a stable position.
In a study correcting bottoming out endoscopically in 14 patients after transaxillary augmentation, the pocket was narrowed with absorbable barbed sutures, and all 14 were satisfied with the immediate result.[2]
How is it prevented?
Bottoming out can arise from a combination of excessive inferior dissection, weakened fold support, implant weight and tissue characteristics. In augmentation, pocket design matched to breast structure and securing fold support matter as much as implant size. Thorough preoperative analysis, precise dissection and appropriate postoperative care help keep the breast shape stable.
Correcting bottoming out: common myths and facts
| You may think… | In practice |
|---|---|
| "Only large implants cause bottoming out." | Making the pocket too low or weak supporting tissue can also cause it. |
| "It rises again with time." | The space the implant has descended into does not narrow by itself. |
| "Revision only needs a new implant." | Narrowing the pocket is part of the correction. |
In a bottoming out consultation I measure the distance from the inframammary fold to the nipple on each side. If that distance has increased, the implant has descended and the pocket needs to be re-set.
Bottoming out is the implant descending too far after augmentation so that the inframammary fold collapses. It differs from simple sagging, and is influenced by the position and size of the pocket and the support of the fold. Beyond implant size, the pocket should be created accurately for each breast structure — preserving fold support, matching dissection to the planned fold, and choosing implant size in proportion to the tissue.
🔬 The research behind this article
These are the international journal papers that support the content above. Select a title to open the abstract on PubMed.
- Aesthetic Plastic Surgery 2017 — anatomical and clinical study of dual-plane augmentationSalgarello M, Visconti G. Staying Out of Double-Bubble and Bottoming-Out Deformities in Dual-Plane Breast Augmentation: Anatomical and Clinical Study. Aesthetic Plast Surg. 2017;41(5):999-1006.Key: bottoming out 6% initially, prevented by anatomical dissectionText [1] · PMID 28656352 · DOI
- Aesthetic Plastic Surgery 2023 — endoscopic correction in 14 patientsCho J, Kim KH, Lee W, Kim SH. Endoscopically Assisted Correction of Malpositioned Breast Implants Using Absorbable Barbed Sutures. Aesthetic Plast Surg. 2023;47(6):2277-2282.Key: pocket narrowed with absorbable barbed suturesText [2] · PMID 37640813 · DOI
🎬 Watch: Dr. Park Seong-Soo on video
Korean-language videos from BongBong Plastic Surgery's official channel and Dr. Park's channel, “Seongsu-ro Doctor”. Titles are translated for reference; selecting one opens YouTube.
Browse the full video archive (Korean) →
Frequently asked questions
Can bottoming out occur immediately after surgery?
A. The implant can sit lower than planned early on, and tissue stretching over time can allow it to progress. Early swelling and normal settling also affect appearance, so actual positional change should be confirmed at examination.
Do larger implants increase the risk?
A. A large implant places a greater load on the fold and surrounding tissue. Where the implant is large or heavy relative to tissue support, the risk of bottoming out can increase.
Does bottoming out always require revision?
A. Where it is clear and the breast shape is deformed, correction through revision can be considered. The method depends on the state of the pocket and the degree of fold damage; repositioning the implant or securing the fold may be used.
📖 References
Select a [number] in the text to jump to the source, and ↩ to return. Only papers whose title, journal and year were verified on PubMed are included.
- Salgarello M, Visconti G. Staying Out of Double-Bubble and Bottoming-Out Deformities in Dual-Plane Breast Augmentation: Anatomical and Clinical Study. Aesthetic Plast Surg. 2017;41(5):999-1006. — Aesthetic Plastic Surgery 2017 — anatomical and clinical study of dual-plane augmentation. ↩
- Cho J, Kim KH, Lee W, Kim SH. Endoscopically Assisted Correction of Malpositioned Breast Implants Using Absorbable Barbed Sutures. Aesthetic Plast Surg. 2023;47(6):2277-2282. — Aesthetic Plastic Surgery 2023 — endoscopic correction in 14 patients. ↩
BongBong Plastic Surgery · Dr. Park Seong-Soo, Medical Director
Contact us for a consultation