Richard A. Baxter, M.D.

The Art Behind Plastic Surgery

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Aug 01

Dr. Baxter

Waterfall ptosis and bottoming out: opposite problems with a similar solution

Posted by Dr. Baxter

Lately we have been seeing more of a type of breast sagging that occurs after augmentation with implants, called waterfall ptosis (ptosis being the medical word for sagging; the “p” is silent.) It can happen years later, or sometimes earlier particularly when a breast lift is done at the same time as implant placement. Basically, what happens is the breast tissue slides downward off of the mound created by the implant – like a waterfall. It is probably more likely to occur in women with larger breasts, because this tissue has to defy gravity to be suspended in front of the implant. As the supportive tissues of the breast weaken over time, the breast loses projection and falls; if the implant stays put but the breast drops, you have the waterfall effect.

How to correct waterfall ptosis with an internal bra

To correct waterfall ptosis, sometimes a breast lift is all that is needed, or a re-do of the previous lift. There are two things that your plastic surgeon will consider: how to merge the breast tissue and the implant mound into a single natural appearing shape, and whether additional support such as an internal bra might help. We like to use Galaflex mesh for this. It’s a naturally derived, slowly absorbing material that is proving to be helpful in maintaining breast shape and upper pole fullness in breast lifts. In the case of waterfall ptosis, it is placed under the skin as an internal bra to wrap the breast and implant together. See an example here.

Correction of bottoming out – the opposite problem

Waterfall ptosis is the opposite of another problem called bottoming out. In this situation, the implant drops too low but the nipple and breast position don’t change. The result is elongation of the distance from the nipple to the bottom edge of the breast. Bottoming out is corrected with internal sutures (called a capsulorrhaphy) in the scar capsule that holds the implant in place. If the capsule is thin and stretched, it may be reinforced with a different application of the internal bra concept, with the mesh placed in the capsule instead of under the skin. See an example here.

The decision to use an internal bra for waterfall ptosis or bottoming out depends on several things, such as the size of the implants. It is a judgment call that your plastic surgeon will make depending on their experience and familiarity with correction of the problem.

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