What causes the dreaded double bubble with breast implant surgery? It is a common cause of concern for patients, and rightly so; a groove across the bottom of the breast is unnatural and unsightly. There are two causes of double bubble, and they often occur together: Lowering the bottom edge of the breast, and animation deformity from dual plane placement. Avoiding double bubble and correction of it requires understanding both of these potential problems.
What causes double bubble?
Double bubble is usually blamed on the implant dropping below the existing bottom edge of the breast, called the inframammary fold or IMF. If the diameter of the implant is too large, then the fold
has to be lowered or the implant will appear too high relative to the nipple. Because the skin of the IMF is anatomically anchored to the ribs with thin ligaments, when these are released to make room for the implant there can be a groove in the skin where the original fold was. This also risks diminishing support for the implant, allowing it to drop further than desired – bottoming out. Surgeons are careful to avoid too much lowering of the fold for this reason, and selecting implants of the right diameter is important. Correction of this type of double bubble is done with sutures in the scar capsule (capsulorrhaphy) to raise the implant and re-establish the IMF.
Implant exchange is sometimes necessary as well, switching to implants with a narrower diameter. However, sometimes the fold was lowered because the nipple to fold distance is short, so a narrower implant plus capsule repair would result in a wider cleavage space. In cases like this I consider using a form-stable (also called gummy bear or anatomic) implant with an oval base because it does not require lowering the fold. The tear-drop profile of these implants has the maximum point of projection lower so it is behind the nipple. (In a round breast without a short nipple-to-fold distance this would be too low.) The oval base ensures that the width of the implants is appropriate.
How dual plane can cause animation deformity and double bubble
But there is often more to it than that: With under muscle implants using the common dual plane method, the pectoral muscle can cause a version of double bubble. This is because the portion of the muscle that attaches to the rib cage is detached from its position typically just above the inframammary fold. It is called dual plane because the muscle covers the top and inner portion of the implant, but not the outside or bottom. As the scar capsule forms around the implant, the edge of the cut muscle adheres to it. Contracting the muscle then exerts a pulling force causing distortion, called animation deformity. The most common form of this is called windowshading, which you see as a groove across the lower breast – double bubble!
It isn’t that difficult to determine which version a patient has: If the groove pulls upward when the pectoral muscle is contracted, it is animation deformity. If not, it is a double bubble from a lowered fold. It is possible to have both. The point of recognizing the difference is that animation deformity cannot be fixed with a capsulorrhaphy. Where windowshading animation exists, the muscle must be re-attached to the chest wall behind the implant. I prefer the split muscle method for this and have used it successfully to correct dozens of cases of animation with double bubble. I use the split muscle method on all of my primary breast augmentation cases where muscle coverage is needed, because this avoids the animation issue. (If muscle coverage isn’t needed, I would do subfascial.)
There are other issues that sometimes have to be taken into account. For example, large implants that have bottomed out forming a double bubble may need additional support. Often I see patients who have had attempted repair with capsulorrhaphy but recurred. This is usually because the capsule was not thick or strong enough to hold the repair, even with large and permanent sutures. Additional implant support may need to be added with an internal bra material such as Galaflex or Strattice. These are often more complicated than they appear, so the experience of a plastic surgeon with a special interest in revision surgery can make a difference.
For examples of double bubble correction visit the breast implant revision page on my site.
