November 01, 2026 | Ask Dr. Agullo, Breast, Breast Revision
Since 2010 I have answered more than a thousand patient questions on RealSelf. Breast revision is by far the most asked-about topic.
I’ve noticed that in almost every breast revision consult, five words come up: Bottoming out. Double bubble. Lateral slide. Waterfall. Capsule. Most of the time, the patient has done some internet research and diagnosed themselves incorrectly. Here are ten revision questions (paraphrased and patient identifying information removed) that I received this year with my answers, lightly edited for the page to try and shed some light on these five terms.
Theme of all of these answers: Revision surgery is required to reconstruct the implant pocket and reinforce it. Don’t count on tissues that have failed you once!
“Have my implants bottomed out again? My nipples look high now.”
Answered on RealSelf, Jun 2026.
Those are the same thing. When the implant bottoms out it slips below the breast fold, pulling the volume of the breast with it. This causes the nipple to appear high. As you can see from your side photo, there is too much volume in the lower part of the breast and not enough up top. Increasing from 200 and 250 cc to 320 and 350 cc resulted in too much weight for the lower pole causing it to stretch a second time. Revision surgery would consist of reconstructing the breast fold with a capsulorrhaphy (plication/suture repair of the implant pocket) to reposition the implant. Given that your tissues have failed you twice I would reinforce the repair with a mesh (GalaFlex or dermal matrix) instead of counting on your tissues to hold up again. I would either keep the same size implant or consider slightly smaller to decrease the weight. A lift revision, without moving the nipple is likely necessary. Once the implant is repositioned your nipple will no longer appear high.
“Is this a double bubble, and can it be fixed without changing the implant?”
Answered on RealSelf, May 2026.
Yes, this can be corrected by revising the capsule only without touching your Natrelle 485 cc implants.
It looks like on your left side your previous surgeon released the capsule at the level of the old IMF (horizontal band of scar tissue marking the location of the old fold) and also performed some lateral capsulorrhaphy (plication/suture repair of the implant pocket) to narrow the pocket on that side. On your right side it looks like he did not fully release the capsule at the level of the old IMF. This is why there is a horizontal crease seen at a lower level on your right side marking the location of the old IMF.
To correct this, your surgeon will need to explore through your old incision and perform a release at the level of the old IMF and perform a capsulorrhaphy on the right side as well. Sometimes this can be reinforced with a piece of GalaFlex Lite placed like a hammock to support the lower pole of the implant pocket and prevent it from forming another fold in the future. This should correct your asymmetry.
This is not an implant issue as there does not appear to be any bottoming out (bottoming out is the lowest point of implant projection below the level of the nipple). If this is also the case when you are examined in person both standing and laying down then a capsule only revision surgery will be all that you need.
“My implants have slid out to the sides. Is that my chest or the surgery?”
Answered on RealSelf, May 2026.
From your front photo, it appears that you may have a combination of both a wider chest wall and possibly implants that have migrated laterally (slid to the side) within implant pockets that were created too widely during your augmentation breast implant surgery.
It is reassuring that there is some cleavage present when you are standing as this indicates that this is not a structural/congenital issue. Instead, this appears to be due to the implant slipping laterally within a implant pocket that was dissected too widely (this is more common the wider your chest is as there is more room for this to happen). This can be corrected with revision surgery to perform a capsulorrhaphy (plication/suture repair of the implant pocket) medially using permanent sutures. This may be further reinforced using mesh such as P4HB or GalaFlex mesh to help prevent the implant pocket from stretching back out.
If the implant width is contributing to this as well (implants are too wide for your chest wall), downsizing your implants can be performed at that time as well.
Subfascial placement can also help narrow a wide chest, although I do not think that this is likely to make as big of a difference as revising the implant pocket will.
I’m also glad to hear that you’re not having any pain 2 years after your breast augmentation. Your photos show an aesthetic concern that is correctable.
“Is my pocket too big or my implant too small? They move when I lie down.”
Answered on RealSelf, May 2026.
What you are describing is called implant displacement/malposition and in your case this appears to be due to a combination of both implant migration laterally (towards your armpit when you lay down on your back) as well as possibly having implants that are a tad smaller in width compared to your natural breast width.
Based on your natural breast width of 13 cm, it appears that your Motiva OTM 285 cc demi implants may be 11.5 to 12 cm in width. This could potentially allow for almost 1 cm of movement on each side for your implant.
The best solution for you would be to undergo a revision breast augmentation in which a lateral capsulorrhaphy is performed (plication/suture repair of the implant pocket laterally using permanent sutures) as well as upsizing to wider and fuller breast implants that would better fill out the implant pocket widthwise. This can be further reinforced using GalaFlex mesh as well.
Placing the implants underneath the muscle (submuscular/subpectoral breast implants) can help in certain situations although I do not think that this would necessarily be indicated in your situation unless you are also noticing rippling (wrinkling of the breast implant) in the upper pole as well. Otherwise, I do not think that this would be necessary in your situation.
“I am having a capsulorrhaphy. Would a narrower implant protect the repair?”
Answered on RealSelf, May 2026.
Yes, a narrower implant would be less likely to stress the suture line from your planned capsulorrhaphy (plication/suture repair of the implant pocket).
Motiva Round Xtra are quite wide (12.8 or 13.1 cm in width) compared to your current implant width (11.7 cm in width). I would consider a Motiva Round Corsé in a 12.25 or 12.5 cm in width. This would be closer to your current implant width and the firmer gel profile may be more amenable to a recently capsulorrhaphied implant pocket.
Keep in mind that wider implants do not help improve cleavage medially. In fact, they place more of a stress on the lateral capsule which may work against the purpose of your planned revision surgery (especially considering your history of lateral implant displacement/migration). Cleavage is improved by releasing the capsule medially as well as performing the capsulorrhaphy.
Unfortunately, the Motiva Corsé profile is not yet available in the United States. Otherwise, I would have recommended this as well. Motiva Full profile implants can also be considered.
Other important recommendations include the following:
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Choosing implants that are high profile in order to maintain projection without increasing the implant width even further
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Wearing a snug supportive bra at all times (even to bed!) and avoiding side sleeping for at least 6 to 8 weeks postoperatively
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Discuss with your surgeon about the use of internal reinforcement/sling (ex: GalaFlex mesh) to further support the capsule while it scars down
“Six months after augmentation with a small lift, what has gone wrong?”
Answered on RealSelf, May 2026.
What you are describing is sometimes referred to as a “waterfall” breast augmentation deformity in which the implant is in a good position but the overlying breast tissue has displaced inferiorly.
This deformity may be amenable to further improvement by performing a breast lift procedure at this juncture (revision fold lift is unlikely to help in this situation). Depending on the degree of excess skin as well as tissue displacement inferiorly, a larger areolar/doughnut/Benelli lift or even vertical/anchor mastopexy (breast lift) pattern may be necessary in order to re-drape the overlying breast tissue superiorly onto the breast implant. In certain situations, this can be further reinforced with mesh (ex: GalaFlex Lite) in order to maintain results long-term.
The suture spitting that you are referring to is a minor wound healing complication and unlikely to contribute significantly to the final aesthetic result.
It has been 6 months since your initial surgery which is adequate healing time to consider a revision procedure if needed.
“Eleven years in, my breast tissue hangs off the implant. Is it time for a revision?”
Answered on RealSelf, May 2026.
The deformity that you are describing is sometimes referred to as a “waterfall” deformity in which the skin/breast tissue envelope has progressively stretched out and fallen inferiorly onto the breast implant which remains higher up in the chest wall.
Revision surgery to refresh your breast lift as well as perform a breast implant exchange to smaller breast implants (ex: Motiva Round or Ergonomix profile) may be helpful to re-drape the skin/breast tissue superiorly and place less of a stretch on your breast skin/tissue envelope (slowing down the effects of gravity even further in the long run). This can be further augmented with soft tissue support mesh (ex: GalaFlex Lite) to act as an “internal bra” in order to further support the breast implant as well as breast skin/tissue envelope.
The contour deformity/dimple on your left breast merits further hands on clinical evaluation by your surgeon to further determine its etiology (ex: capsular contracture, implant malposition/migration, asymmetric implant size relative to implant pocket size, breast tissue thinning/asymmetry, etc.). This can potentially be addressed at the time of surgery as well if needed.
“I want more upper fullness. Can I avoid a lift?”
Answered on RealSelf, Jun 2026.
Since 2/3 of the plastic surgeons that you were seen by do not feel that you are a candidate for a breast lift procedure, I would defer to their recommendations over mine based on remote assessment.
In your pictures, your upper poles are somewhat flat (especially on the left). Saline breast implants placed above the muscle will become progressively flatter with time (especially 14 years down the road). Your areolae/nipples are somewhat low and the breast tissue hangs somewhat inferiorly (below the nipple/areola complex).
Whether one is a candidate for a breast lift or not largely depends on nipple position relative to the breast fold. Yours are borderline since they are on the fold. If your nipples/areolae were lower, increasing implant size/volume will not correct this (the breast implant will remain where it is and the breast tissue will progressively fall off of the breast implant even further creating an even worse “waterfall” deformity with additional ptosis/sagging).
In your case, I personally might opt for a small circumareolar/doughnut/dish/Benelli lift in order to improve the upper pole fullness even further.
Regarding upper pole fullness, this is largely determined by implant projection as well as cohesiveness/stiffness of the silicone gel (not so much submuscular versus subfascial placement). I completely understand your reluctance to place the breast implants below the muscle due to breast distortion when working out; however, realize that this also comes with a tradeoff (more visible breast implant edges/less upper pole soft tissue coverage).
“My implants look like disks on my chest. What makes them look natural?”
Answered on RealSelf, May 2026.
Yes, you do have “disks on your chest” at this juncture. Since your breast implants are subfascial, they are on top of (not under) the pec muscle. Therefore, they will not slide under the pec muscle when you are supine. Furthermore, given your prior lollipop lift as well as relatively thin upper envelope, I do not anticipate that this “disk” deformity will improve further even after the swelling subsides.
If I was revising your breast implants in your situation, I would perform a:
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Medial capsulorrhaphy (suture closure of the medial aspect of the implant pocket to prevent the breast implants from residing too medially) in combination with a
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Lateral capsulotomy (release of the scar tissue on the outer/lateral aspect of the implant pocket to allow the breast implants to slide more laterally onto the chest wall) and
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Exchange to a lower profile/narrower base width implant (narrower base width than the 220 ergo mini with a lower profile) so that you do not flatten out as much when supine as well as
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Fat grafting (hybrid breast augmentation) to the superior and especially superomedial aspects of the breast implants in order to camouflage the implant edges especially given your relatively thin envelope.
I would discuss this option with you further in person if we meet.
Also, consider conversion to dual plane at that time if your skin envelope becomes even thinner.
Lastly, don’t pass up on the fat grafting! Only a small amount of fat is needed with a disproportionately large aesthetic improvement!
“Saline implants for 25 years and a grade 3 capsule on one side. Will it come back?”
Answered on RealSelf, May 2026.
Unfortunately, after 25 years with your breast implants placed below the muscle (saline), there is a high chance that you will develop at least a grade III capsular contracture at some point down the road on at least one side.
Your chance of this recurring, however, will be dependent on what procedure is actually performed at the time of surgery. Ideally, this would consist of:
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A total capsulectomy on the side in question in combination with placement of your new breast implant into a neo-subpectoral pocket (essentially a new dual plane dissection on normal/unscathed tissue) as well as
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Lower pole reinforcement with either ADM or a GalaFlex Lite.
With these combined modalities, the recurrence rate is in the single digits in most of the series that I pay attention to. Otherwise, if your new breast implant is placed back into the scarred out pocket (without a plane change), you are pretty much rolling the dice!
Regarding your other question, yes, I do feel that performing the implant removal/explantation at one point in time and then reimplantation at a later date would be more challenging than simply performing a one stage procedure (removal of the old implants in combination with placement of new implants at the same visit). The pocket will scar down and the tissues will become even thinner without the breast implant providing some support to the breast mound. It would likely be necessary to perform some sort of lift procedure as well as fat grafting (hybrid procedure) at the time of your second procedure in order to optimize the tissues before your new breast implant could be placed.
Whether one stage versus two stage is best, however, would be dependent on seeing actual pictures of you at the time of an in person consultation.
The short version
| What you see | What it usually is | What fixes it |
|---|---|---|
| Nipple looks high, bulk sits low | Bottoming out (one event, not two) | Rebuild the fold (capsulorrhaphy), mesh backup, hold or drop size |
| A crease under the new fold on one side | Double bubble, old fold band not released | Release the band, capsulorrhaphy, often GalaFLEX Lite; the implant stays |
| Breasts drift apart lying down | Lateral pocket too wide for the chest | Lateral capsulorrhaphy with permanent sutures, mesh, narrower implant if the base is too broad |
| Tissue hangs off a well-placed implant | Waterfall | A real lift (vertical or anchor), not another fold revision, often a smaller implant |
| Firm, high, painful on one side after years | Capsular contracture | Total capsulectomy, new plane, mesh along the lower pole |
Why choose Dr. Agullo
I am certified by the American Board of Plastic Surgery and the American Board of Surgery, completed my plastic surgery fellowship at the Mayo Clinic, and serve as Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly has listed me as a Top Doctor every year from 2014 through 2026. Breast revision is a large part of my practice: pocket repair with permanent sutures, GalaFLEX or P4HB mesh as an internal bra, implant exchange and lift refresh, done together when they belong together.
Ready to talk?
Bring your photos and your implant card. Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com/appointments. You can also read my answers on RealSelf. #StayBeautiful
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