The friendly foe to all of us, gravity, enables us to live on this planet, but unfortunately to show our age with skin sag. Another victim of this force is the breast implant which over time can settle downward. When this process proceeds to an undesirable degree, we refer to the condition with the unmedical-sounding moniker “bottoming out.” Unfortunately, the fibers which lend support to the breast, called Cooper’s ligaments, often with changes of aging, major weight changes, medications, nicotine, or post-pregnancies lose their strength allowing the weight of the implant to bear downward with resultant position change. This process may occur on both right and left sides, or just one side. It is more common in slender women who may not have as many support fibers. What is referred to as the subpectoral or submuscular positioning of a breast implant, a common technique now for breast augmentation or reconstruction, places the implant beneath the lower edge of the muscle which can allow the mammography doctor the opportunity to pull the breast forward during a mammography examination so that it is separated visually from the implant, for enhancement of breast study. Despite this “pocket” for the implant the muscle does not provide support upward of the implant, and the lower portion of the implant simply sits beneath the breast tissue atop the rib cage. Bottoming out can then occur.

What can be done to treat or to help prevent bottoming out? The choices of a lighter weight, i.e. smaller, implant may help. Additional muscle tissues brought beneath as a sling may help, but may adversely affect the appearance of the delicate groove beneath the breast mound called the inframammary fold. Textured-surface implants may help hold the position by “grabbing” onto the surrounding walls of tissue (but may increase other undesirable effects such as skin surface wrinkling). The use of support materials, such as slowly dissoluble screen-type fabrics, or even preserved human or animal-tissue scaffolds may be used. Until such time as we are able to live upside down or slow down the gravitational spin of our planet without creating other havoc, we will continue to study and hopefully to find ways to combat bottoming out.