Bottoming out is a complication of breast implant surgery that consists of the descent of the inframammary fold with inferior displacement of the implant, causing breast asymmetry. Release of the lower pole for adjustment of the inframammary fold1 can result in insufficient capsular support, and the downward pectoral muscle action can contribute to push and keep the implant in a lower position.
There are different surgical techniques with which to correct bottoming out, such as single or multilayer capsulorrhaphy with or without mirror-image selective capsulotomy, capsular flaps, polypropylene mesh, cadaveric dermis, AlloDerm (LifeCell Corp., Branchburg, N.J.), and intracapsular allogenic dermal grafts.1–5 A new simple technique is presented for correcting the implant displacement recreating a new inframammary fold with an external approach.
The desired new inframammary crease is marked preoperatively in the standing position. The closed capsulorrhaphy is performed under local anesthesia. The implant must be protected, and displaced cranially with one hand to prevent accidental perforations. A 3-mm incision made with a no. 11 blade is performed at the level of the inframammary fold. A custom-made aspiration scrape cannula (2 mm in diameter) is introduced through this incision. The lower pole of the capsule is scraped with the cannula with the aim of provoking a fibrotic process and scarring adhesions. After this, a suture is performed by means of three nonabsorbable polypropylene external stitches deep to the periosteum of the sixth and seventh ribs, creating the new desired inframammary fold following the preoperative markings. The skin is protected from the stitches using petrolatum gauze. This retention suture collapses the redundant capsule and keeps the implant in the desired position during the healing process. Stitches are removed on the fifth postoperative day. An elastic dressing to define the new submammary fold is worn for 1 week.
With this technique, the new inframammary fold is created at the desired site by means of the stitches and the capsular adhesions caused by the cannula scrape. The removal of the stitches prevents possible implant capsular erosion from the knots. It is not indicated in cases with implant displacement combined with capsular contracture.
We report the case of a 26-year-old woman who underwent an axillary subpectoral augmentation mammaplasty (350-cc silicone cohesive-gel implant; Mentor Corp., Santa Barbara, Calif.). In the second postoperative month, she presented a 4-cm inferior displacement of the right implant (Fig. 1). She underwent surgical correction by means of this technique.
At 12 months after the procedure, the clinical control shows an adequate implant position, without recurrence of bottoming out (Fig. 2).
We present only a case report here, although we have a short series of six patients treated successfully with this technique. This technique is an option to keep in mind because it is a simple, rapid, and useful method with which to correct bottoming out with local anesthesia, recreating a new inframammary fold with an external approach.
Ivan Mañero, M.D.
Patricia Montull, M.D.
Eva Guisantes, M.D.
Plastic and Reconstructive Surgery
1.Baxter R. Intracapsular allogenic dermal grafts for breast implant-related problems. Plast Reconstr Surg.
2003;112:1692–1696; discussion 1697–1698.
2.Chasan P. Breast capsulorrhaphy revisited: A simple technique for complex problems. Plast Reconstr Surg.
2005;115:296–301; discussion 302–303.
3.Spear SL. Breast capsulorrhaphy. Plast Reconstr Surg.
4.Carlsen L, Voice D. Using a capsular flap to correct breast implant malposition. Aesthetic Surg J.
5.Massiha H. Reconstruction of the submammary crease for correction of postoperative deformities in aesthetic and reconstructive breast surgery. Ann Plast Surg.
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