South Florida Plastic Surgery Associates - Don R. Revis, MD

Internal Bra Technique for Bottoming Out,
Double Bubble and Synmastia Repair

Correcting Improper Positioning of Breast Implants

Dr. Revis uses his innovative Internal Bra technique for correction of bottoming out, double bubble and synmastia (also known as symmastia).

Dr Revis Internal Bra

What is bottoming out?

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.

Bottoming Out Correction: Before Bottoming Out Correction: After
After Right Breast Repair After Left Breast Repair
Intraoperative photos show a repair of severe bottoming out and lateral displacement of both breasts using the Internal Bra procedure. The incisions along the lower areolar borders will be closed and will heal inconspicuously.
Bottoming Out Correction: Before Bottoming Out Correction: After
Before After
Photos show a 32 year old out of state patient with bottoming out and a wide gap, at pre-op and six weeks post-op. An Internal Bra procedure was performed, along with an implant exchange from 275cc moderate plus profile silicone gel to 325cc moderate plus profile silicone gel.

Bottoming out 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.

Example of bottoming out breast implant deformity Example of bottoming out breast implant deformity
Bottoming Out: Example 1 Bottoming Out: Example 2

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.

Don Revis

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.

Example of double bubble breast implant deformity Example of double bubble breast implant deformity
Double Bubble: Example 1 Double Bubble: Example 2

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?

To correct bottoming out, Dr. Revis performs the Internal Bra procedure. 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, 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. 

Bottoming Out Correction: Before Bottoming Out Correction: After
Before After
Photos show a 26 year old international patient with bottoming out and rippling, at pre-op and twelve weeks post-op. An Internal Bra procedure was performed and Strattice placed bilaterally, in addition to an implant exchange from 700cc high profile silicone gel to 800cc ultra high profile silicone gel.

How long will the Internal Bra last?

With Dr. Revis' technique, he has found that after the Internal Bra is fully healed (around 12 weeks), it usually lasts for many, many years. This truly anatomical correction places the tissues back in their proper orientation, the way the body was designed. The patient below is one example of an excellent long term result.

Bottoming Out Correction: Before Bottoming Out Correction: Before
Before After
Photos show a 28 year old patient with bottoming out, at pre-op and 9 years post-op, with no change of implant size, demonstrating the excellent long term support provided by the Internal Bra procedure.

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

Absolutely. Approximately 40% of patients who undergo the Internal Bra procedure 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 technique when it is performed correctly with permanent sutures.

What is synmastia?

Synmastia (shown below) is present when one or both implants are positioned too close to the midline over the breastbone (sternum). This means that the pockets, or capsules, surrounding the implants are too medially placed. Please see Synmastia / Symmastia for more information on this complex issue.

May I see examples of the Internal Bra procedure?

Please click the links below to review pre- and post-operative photos of the Internal Bra procedure, as well as numerous examples of other breast implant problems.

Internal Bra Procedure Before & After Photos
Breast Augmentation Revision Before & After Photos

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



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