What bottoming out is
Bottoming out is a form of implant malposition in which the implant descends below the natural inframammary fold (the crease under the breast). The implant ends up sitting too low on the chest, which shifts all the fullness to the bottom of the breast and leaves the upper pole looking empty. It's a gradual, structural problem — the tissue and fold supporting the implant have stretched or given way.
The signs
Bottoming out has a recognisable pattern:
- The nipple points upward — because the implant has dropped below it, the nipple ends up high on the breast mound, sometimes appearing to point skyward.
- Fullness sits low — most of the volume is in the lower breast, with a flat or empty upper pole.
- The fold drops — the crease under the breast sits lower than it should, and lower than the other side if only one is affected.
- The breast looks "long" — an increased distance from nipple to fold.
- A double bubble can appear if the old fold remains visible above the dropped implant.
Why it happens
Bottoming out is fundamentally about the lower breast losing the support that holds the implant in place. Contributing factors include:
- Weak or thin tissue in the lower pole that can't hold the implant's weight long-term.
- The inframammary fold not being adequately supported or reinforced at the original surgery, or being over-lowered.
- Large or heavy implants that place more downward force on the tissue than it can sustain.
- Over-dissection of the pocket below the fold during the first operation.
- Time and gravity gradually stretching the tissue.
How bottoming out is repaired
The core of the repair is to rebuild support under the implant and restore the fold to the correct height — often described as creating an "internal bra." Techniques include:
- Capsulorrhaphy — internal sutures that tighten the lower pocket and lift the fold back to where it should be, recreating proper support.
- Acellular dermal matrix (ADM) or mesh reinforcement — an internal supportive layer that strengthens the lower pole, especially valuable when the natural tissue is thin or has already failed once.
- Choosing an appropriately sized implant — sometimes a smaller or lighter implant reduces the downward load so the repair lasts.
- Pocket or plane adjustment — revising or changing the implant pocket to give a stable, correctly positioned result.
The aim is a durable repair: not just lifting the implant once, but reinforcing the lower pole so it stays up. This overlaps with the broader correction of implant malposition, where the principles of repositioning and reinforcing the pocket apply across the different malposition types.
Making the repair last
Because bottoming out is a failure of support, the most important factor in a lasting fix is reinforcing that support properly — which is why matrix or mesh is often used, and why implant size is reconsidered. Choosing a surgeon who routinely performs these internal-bra repairs matters, since the durability of the result depends on the quality of the reinforcement. The individualised planning is described on our what is breast revision page.
The bottom line: bottoming out is the implant dropping below the fold, recognisable by high nipples and a low, full lower breast. The fix rebuilds the fold and reinforces the lower pole — an internal bra — so the implant is supported in the right position and stays there.
