Bottoming Out & Implant Malposition

What does implant malposition look like?

Implant malposition is a broad term for a breast implant that has settled somewhere other than where it was intended to sit. Patients rarely use the medical word; they say their implants have “dropped”, “gone to the sides”, “never came down” or that they can see “a line across the breast”. These are four different patterns, and each has its own cause and its own correction.

• Bottoming out. The implant has slid below the natural fold beneath the breast. The lower breast looks long and over-full, the nipple seems too high or points upwards, and a fold scar may now be visible on the underside of the breast rather than hidden in the crease.
• Lateral displacement. The implant has drifted outwards towards the armpit. The gap between the breasts widens, cleavage disappears, and the implants fall to the sides when you lie on your back. This is the opposite problem to symmastia, where the implants move too far towards the middle.
• High-riding implants. The implant sits too high on the chest, with fullness concentrated above the nipple and a lower breast that looks empty or tight.
• Double bubble. A second crease is visible across the lower breast, so the breast shows two curves instead of one smooth contour.

One side can be affected, or both, and more than one pattern can exist at the same time — an implant can bottom out and drift laterally together.

What causes implants to move out of position?

The implant itself rarely fails. What fails is the support around it: the pocket in which the implant sits and the fold that forms its floor. Most malposition is a support problem.

Why does bottoming out happen?

The inframammary fold is a band of connective tissue that acts as the shelf at the base of the breast. It can give way when:

• the implant is heavy or wide relative to the patient’s tissue, so the fold carries more load than it can hold over time;
• the fold was lowered at surgery to fit the implant and was not reinforced afterwards;
• the patient’s tissue is naturally thin or elastic, or has been stretched by pregnancy or weight change;
• the lower pocket was dissected wider than the implant needed.

Why do implants drift to the sides?

Lateral displacement usually follows a pocket that is too wide on the outer side, either from the original dissection or from gradual stretching. An implant that is wider than the breast base, a chest wall that curves away naturally at the sides, and the repeated action of the chest muscle on an implant placed beneath it can all encourage the implant to move outwards, especially when lying down.

Why do implants sit too high?

In the first weeks it is normal for implants to sit high; they settle over the following months as swelling resolves and the lower breast stretches to accommodate them. An implant that is still high after this period is usually held up by a tightening scar capsule — capsular contracture — or by a lower pocket that was not released enough.

What causes a double bubble?

There are two versions. In the first, the implant sits below the original fold, but the fold’s attachments are still there, so a crease runs across the lower breast with implant bulging beneath it. In the second, the implant sits high while the patient’s own breast tissue slides down in front of it — often after pregnancy or weight change — so the breast shows a second contour above. The first is a fold problem; the second is closer to sagging around the implant, and is often corrected with a lift, as explained on the sagging breasts page.

How is implant malposition diagnosed?

Diagnosis starts with a careful examination, standing and lying down, with measurements compared side to side: nipple to fold, fold to the base of the breast, the gap between the breasts and the width of the breast base. You may be asked to tense your chest muscle, which shows whether the muscle is moving the implant. Photographs from after the original surgery, if you have them, are very useful.

Imaging is not always needed for malposition alone, but it is arranged when the examination raises another question — firmness suggesting capsular contracture, a change in shape suggesting rupture, or no record of which implant is in place. Ultrasound or MRI identifies the implant and the state of the capsule so the revision is planned on facts.

Can implant malposition be fixed without surgery?

Honestly, no. Once the pocket has stretched, nothing applied from the outside can tighten it again. Supportive or underwire bras, bands and taping may make the breast more comfortable and can help protect it from further stretching, but they cannot return an implant to its original position. Massage does not correct malposition and can make a stretched pocket worse. What non-surgical measures can do is buy time while you decide, and there is no urgency to correct malposition on its own unless it is causing discomfort or distress.

Which operation corrects implant malposition?

The correction is a form of breast implant revision, planned around the specific pattern. The central manoeuvre is capsulorrhaphy: the over-stretched part of the pocket is closed with rows of permanent internal sutures, and the implant is returned to its correct position. Dr. Paulo Michels performs it with the Internal Bra technique, which rebuilds the fold as a firm shelf and, where the tissue is weak, reinforces it with flaps of the patient’s own fascia — rather than a mesh as standard.

Pattern	Main correction
Bottoming out	Lower capsulorrhaphy; fold rebuilt with permanent sutures; often a lighter or narrower implant
Lateral displacement	Lateral capsulorrhaphy to close the outer pocket; implant width matched to the chest
High-riding implant	Release or removal of the tight capsule, or release of the lower pocket; implant exchange if indicated
Double bubble (fold type)	Old fold released or adjusted; implant repositioned; new fold reinforced
Double bubble (sagging type)	Breast lift with implant repositioning or exchange

The implant is often exchanged during the same operation. A pocket that stretched under a large or heavy implant is more likely to hold when the new implant is narrower or lighter and matched to the measured width of the chest. Implants used in revision are premium cohesive silicone with smooth or nano-textured surfaces (Motiva, Mentor, Polytech), inserted with a Keller Funnel. Where appropriate, the implant is moved to a Dual Plane position.

The full details of how the pocket is rebuilt, and how revision is combined with lifts, exchanges or capsulectomy, are on the Internal Bra procedure page. If you are weighing correction against removing implants altogether, the explant page and the guide to when implants need replacing will help.

What does recovery look like?

Recovery follows the pattern of a breast augmentation, with one difference: the internal sutures that rebuild the pocket must heal without tension, so the six-week protection period matters more than after a first operation.

• Light walking from the first day.
• Sleeping on your back for four to six weeks.
• A support bra day and night for four to six weeks.
• Desk work usually within about a week.
• No high-impact exercise or upper-body weights for four to six weeks.

Ultrasound-guided nerve blocks placed during surgery keep the first days comfortable. The shape settles over the following months. The augmentation recovery guide gives a week-by-week picture.

What are the limits and risks of correction?

Correction reliably improves the position of an implant, but it cannot change your tissue quality, the shape of your chest wall or the natural asymmetry most women have. Thin, stretched tissue and very large implants remain factors that can affect any result over the years. Risks include bleeding, infection, seroma, changes in nipple sensation, asymmetry, capsular contracture and the possibility that a further adjustment is needed. The internal sutures may occasionally be felt in very thin patients, or cause a temporary pulling sensation that settles with healing.

When should I see a surgeon?

See a surgeon if you notice a change in the position or shape of one or both breasts after the first few months, if the fold scar has moved onto the breast, if the implants now fall to the sides or touch in the middle, or if a breast has become firm, painful or distorted. A change in shape is not always malposition; it deserves examination either way.

How is implant malposition assessed at the consultation?

Dr. Paulo Michels, a Brazilian board-certified plastic surgeon with over 18 years’ experience, examines you standing and lying down, measures both breasts, reviews any records of the original surgery and arranges imaging if needed. Crisalix 3D simulation can show the effect of a different implant size or shape. You leave with a clear explanation of which pattern you have, why it happened and what correcting it involves. Consultations are in English, Portuguese or Spanish; the practice is WhatsApp-first on +971 50 106 7981, and all surgery takes place at Elyzee Hospital in Abu Dhabi, where patients from Dubai and across the UAE are seen routinely with visits grouped to reduce travel.