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Removing the Ambiguity from the Double Bubble

Ricci, Joseph A. M.D.; Driscoll, Daniel N. M.D.

Plastic and Reconstructive Surgery: December 2015 - Volume 136 - Issue 6 - p 864e–865e
doi: 10.1097/PRS.0000000000001794

Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

Correspondence to Dr. Ricci, Division of Plastic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, Mass. 02114,

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The double-bubble deformity represents an established and widely recognized complication following breast augmentation. Recently, we have noted on numerous Web sites, journal articles, and even at the weekly conference at our own institution, a pervasive incorrect use of the term “double bubble” to describe what should be considered two distinct breast entities: the true “double bubble” and the “snoopy nose” deformities.

In the classic double-bubble deformity, patients have two characteristic parallel creases running transversely across the lower pole of the breast (Fig. 1). The superior fold represents the remaining native inframammary fold, whereas the lower fold represents the inferior pole of the implant, defined by the lowest level of dissection of the new periprosthetic pocket or the level to which the implant has spontaneously descended.1 Several other mechanisms may cause the formation of a double-bubble deformity, including capsular contracture.1,2 Treatment of this problem is well described to include effacement of the undesirable fold by complete lysis of the horizontal fascial connections between the dermis and the superficial fascia.3

Fig. 1

Fig. 1

Although often misidentified as a double-bubble deformity, the snoopy nose deformity is a completely different entity that stems from a completely different mechanism and is solved by different surgical techniques compared with the classic double bubble. The snoopy nose deformity earns it name from the similarity between its appearance on a lateral view of the breast and the profile of the cartoon dog Snoopy’s nose4 (Fig. 2). Unlike the classic double bubble, the snoopy nose deformity is not caused by issues with the inframammary fold, but rather by ptosis of the breast gland relative to the implant causing a superior implant-to-nipple malposition.

Fig. 2

Fig. 2

In some patients, this deformity develops many years after surgery as the breast tissue begins to sag with age, causing it to effectively “slide off” the implant. In other cases, the patient had preexisting breast ptosis that required mastopexy at the time of augmentation for correction, but for some reason, only an augmentation was performed rather than a concurrent mastopexy-augmentation. In these cases, the surgeon will often use an overly large implant to try and fill the excess skin and “lift” the breast, thus creating a superior implant bulge relative to an inferiorly positioned nipple and breast tissue, creating the snoopy nose deformity. Unlike the classic double bubble, once present, the snoopy nose deformity can usually be corrected by performing a mastopexy, and no work needs to be done to the original inframammary fold.

In conclusion, we hope that this serves as a first step toward clarifying the ambiguity associated with the term “double bubble.” Clearly, the classic double-bubble and snoopy nose deformities represent two very different deformities with different causes and treatments; there is little utility in classifying them under one umbrella term. We urge both junior and senior surgeons alike to standardize the terminology of these challenging yet different problems in the hopes that we can improve patient outcomes.

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The patient provided written consent for the use of her images.

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The authors have no financial interests to disclose. This work has not been supported by any sources of funding.

Joseph A. Ricci, M.D.

Daniel N. Driscoll, M.D.

Division of Plastic Surgery

Massachusetts General Hospital

Harvard Medical School

Boston, Mass.

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1. Handel N.. The double-bubble deformity: Cause, prevention, and treatment. Plast Reconstr Surg. 2013;132:1434–1443
2. Lee HK, Jin US, Lee YH.. Subpectoral and precapsular implant repositioning technique: Correction of capsular contracture and implant malposition. Aesthetic Plast Surg. 2011;35:1126–1132
3. Bayati S, Seckel BR.. Inframammary crease ligament. Plast Reconstr Surg. 1995;95:501–508
4. McGibbon BM.Goldwyn RM. Case report (case 23). Plastic and Reconstructive Surgery of the Breast. 1976 Boston Little Brown:528–529
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