What is “bottoming out” after breast surgery?

This is a frequently misunderstood concept. Even some plastic surgery websites get it wrong!

Traditionally, bottoming-out was the term applied when the lower half of the breast skin stretched and lengthened out after a traditional “inverted-T” style breast reduction surgery. This lower-pole stretch could give a characteristic appearance to the breast, with the following features:

1) the illusion of an overly high placement of the nipple,
2) a vertically oblong-shaped breast,
3) loss of upper pole fullness with excess fullness in the lower half of the breast (more “teardrop” than “round”), and
4) an upward-oriented nipple.

The usual treatment was to surgically remove the stretched out skin, using a horizontal ellipse pattern, placed in the infra-mammary crease area. This fixes the problem nicely, especially in women that already have a scar in the crease.

Recently, the same term has been applied to certain complications after breast implant surgery, and this is where the terminology sometimes goes astray. Two situations can look similar to the untrained eye….

A) Expansion of the pocket. In this situation, the inframammary crease descends to a abnormally low position and the implant falls downward into a lower position with gravity. Look for the distance between the original incision (if it was in the crease) and the crease itself (which is moving downward) to be greater than it was originally.

B) True bottoming out. Here the crease level stays fixed. The scar position does not migrate. The skin of the lower part of the breast is ballooning out. As before, a skin tightening operation – a modified mastopexy – is the usual treatment.

Why is it important to make this distinction? Because the treatments are quite different.

Treatment of pocket expansion typically involves a few steps in the operating room. Make sure the pocket is not scarred down or encapsulated in the upper part of the breast. Suture plication of the abnormally opened lower part of the breast with permanent sutures is then used to close off the lower portion of the pocket. Additionally, textured implants, which have a bit of a velcro-effect with the chest wall, sometimes help to keep in implant in the desired position, and can be considered.

Despite good surgical technique, sometimes it’s the patient’s tissue that doesn’t hold up. Sutures can pull through the weak tissue, resulting in a return of the abnormally low implant position problem in about 20% of patients. This seems to happen in women who are very thin, who have larger volume implants (greater than about 400 cc), or who are overly active after the repair surgery and don’t allow things to heal properly.

Recently, a technique originally used in reconstructive breast surgery is gaining popularity for these difficult and challenging cases. A large sheet of dermal matrix, known commercially as “Strattice” or “Alloderm” is used to create a sling, running from the lower part of the pectoral muscle down to the desired infra-mammary fold level. Results of this have been fairly good, but the cost of the material is very high – about $2000 per side, just for the Strattice alone. Talk about “sticker shock”!

As usual, the best treatment of a problem is to avoid it in the first place. Appropriate implant selection, surgical technique which preserves the infra-mammary crease whenever possible, and appropriate post-operative care by both patient and surgeon will go a long way to minimize these issues. But sometimes, Mother Nature just doesn’t co-operate…and it’s back to the operating room.