Internal Bra for Bottoming Out & Double Bubble Repair

Bottoming out is a specific example of a post-operative problem requiring a thorough, systematic approach and innovative surgical techniques. Dr. Revis has seen a dramatic increase in the number of patients presenting from other offices and other countries with bottoming out of one or both implants. Currently, this is the most common revision he performs, usually two to three times a week.


Before	After
Photos show a 32 year old patient with bottoming out and a wide gap, at pre-op and six weeks post-op. An Internal Bra was performed, with implant exchange from 275cc moderate plus profile silicone gel to 325cc moderate plus profile silicone gel.

What is bottoming out?

Bottoming out (shown below) is present when one or both implants are positioned too low or too lateral on the chest wall in relation to the nipple position. This means that the pocket, or capsule, surrounding the implant has become too low on the chest wall or rests too far laterally when lying down.

This may represent overdissection of the pocket in the region of the inframammary crease during surgery, cutting of the lower portion of the pectoralis muscle, or may occur naturally over time and under the effects of gravity in patients with implants that are placed above the muscle or only subpectorally (partially submuscular) when compared to total submuscular placement of breast implants.

What is double bubble?

Double bubble (shown below) is present when there is a groove along the breast below the nipple giving the appearance of the breast sitting on top of the implant. This is sometimes observed in patients with bottoming out. The groove represents the old inframammary crease that has actually lifted off of the chest wall and allowed the implant to slip out from underneath the breast.

What are the symptoms of bottoming out?

Most patients report that they have a hanging or heavy sensation because of lack of support for the implant. This may also be accompanied by a mild discomfort or a real pain. Rippling may be present as well because of the thinned tissues along the bottom of the breast.

How is bottoming out diagnosed?

Bottoming out is usually diagnosed by the patient or by a plastic surgeon. An experienced plastic surgeon should be able to diagnose bottoming out from photos alone.

When diagnosing yourself, in addition to the heavy or uncomfortable feeling, you may also notice a worsening of your implant position in relation to your nipple position. This may cause the appearance to be unattractive and even uncomfortable when wearing no bra. Because the implants hang too low, you may not be comfortable going braless. You may need to wear a pushup bra to correctly position your implants or to keep them from falling far apart and even into your armpits when lying down.

Proper implant position means that the nipple is centered on the center of the breast implant. If more of the implant rests below the nipple than above the nipple, then you have bottoming out.

Can bottoming out be corrected non-surgically?

Unfortunately in Dr. Revis’ experience, he has found that the internal bra procedure is required to correct bottoming out. Bottoming out is a progressive disorder that generally gets worse over time as the effects of gravity cause the implant to sag within the tissue envelope of the breast. The heavy or uncomfortable feeling usually also worsens with progression of the bottoming out.

Will switching to smaller implants correct bottoming out?

Switching to smaller implants alone will not correct bottoming out. The new implants will still sink to the bottom of the pocket, taking even more volume away from the upper pole fullness. In my experience the only true, long term correction for bottoming out is an Internal Bra procedure.

How can bottoming out be corrected?

Dr. Revis has developed a special technique that has the effect of creating an "internal bra" using strong, permanent suture techniques. Using special lighted retractors, Dr. Revis expands the implant pockets (capsulotomy) superiorly and medially, creating room for the implants to be repositioned at a higher level- creating better cleavage, a more youthful shape, and improved fullness in the upper pole of the breast.

Dr. Revis then closes part of the pocket that rests laterally and inferiorly (the internal bra), thus preventing the implants from resting too low or falling too laterally to the sides. Dr. Revis uses permanent sutures for a long-lasting result. These sutures are carefully placed so that the suture material is never in direct contact with the implants inside the body.

May I switch to larger implants when I have my bottoming out corrected?

Absolutely. Approximately 40% of internal bra patients keep the same size implants, 40% increase the size of their implants, and the remaining 20% reduce the size of their implants. The size/weight of the implants has no relationship to the success or the long-lasting nature of the bottoming out correction with the internal bra when it is performed correctly with permanent sutures.

May I see examples of the internal bra procedure?

Please click the Breast Augmentation Revision link below to review pre- and post-operative photos of the internal bra for bottoming out, as well as numerous examples of other breast implant problems.

Please call (954) 630-2009 for further information or to schedule your complimentary consultation.