A common theme in Dr. Farhad Rafizadeh’s Morristown consultation room — and one that shows up repeatedly on his RealSelf Q&A page — comes from women whose implants have shifted out of position, changing the shape of the breast even though the implant itself is intact.
“A while after my breast augmentation, my implant seems to be sitting too low and I’ve started to see a second crease under the breast. My nipple points up now. What is this, and can it be fixed?”
This is the classic presentation of breast implant malposition — specifically bottoming out with a double bubble. It is one of the most common reasons women across Northern New Jersey seek breast implant revision, and the reassuring news is that each type of malposition has a well-established surgical fix.
What Is Breast Implant Malposition?
Malposition simply means the implant is no longer where it should be on the chest. Unlike capsular contracture — which is a hardening problem — malposition is a position and shape problem. The implant may have drifted too low, too close to the middle, too far to the side, or created an extra crease. These can happen individually or in combination, and they are what a revision surgeon is trained to diagnose precisely before planning a repair.
The Four Common Types of Malposition
| Type | What you see |
|---|---|
| Bottoming out | Implant sits below the natural crease; upper breast looks empty; nipple points up; long distance from nipple to fold. |
| Double bubble | A second horizontal crease across the lower breast, so the breast looks like two stacked bulges. |
| Symmastia | Implants drift toward the sternum and the pockets meet in the middle, erasing the cleavage gap (“uniboob”). |
| Lateral displacement | Implants slide off to the sides, especially when lying down, so cleavage is lost and the breasts point outward. |
Bottoming Out
Bottoming out is the most frequently searched of the four, and for good reason: it changes the whole silhouette. As the implant drops below the inframammary fold, the top of the breast flattens, the nipple rotates upward (sometimes called a “stargazer” nipple), and the lower pole stretches. It happens when the lower tissue or the fold cannot hold the implant — commonly from an implant that is too large and heavy, a pocket made too low at the original surgery, or naturally thin tissue.
Double Bubble
A double bubble appears when the implant slips below the original breast fold while that fold stays tethered to the skin, creating a visible line across the lower breast. It is especially common in women with a constricted or tuberous breast shape, where the fold is tight and high. Depending on the cause, correction ranges from releasing the fold to rebuilding the pocket.
Symmastia
Symmastia is one of the more difficult malpositions to correct. When the pockets are over-dissected toward the midline — often in pursuit of more cleavage — or the implants are simply too wide, the two implants meet in the center and the natural gap over the breastbone disappears. Fixing it means reconstructing the midline wall of the pocket, usually with strong internal sutures and often reinforcing support.
Lateral Displacement
Here the implants fall toward the armpits, most noticeably when lying down, leaving a wide, flat center. It is corrected by tightening the outer (lateral) pocket so the implants stay centered on the chest.
What Causes Implants to Move Out of Position?
Malposition is usually the result of the balance between the implant and the tissue tipping the wrong way. The recognized contributors include:
- An implant that is too large or heavy for the patient’s tissue — the single most common driver of bottoming out.
- A pocket dissected too low or too far toward the midline at the original augmentation.
- Thin or weak breast tissue and loss of skin elasticity over time.
- Gravity acting on the implant year after year.
- Underlying breast shape, such as a constricted or tuberous breast, that predisposes to a double bubble.
- Trauma or capsular contracture pulling an implant off center.
How Dr. Rafizadeh Corrects Malposition
Every malposition repair is a rebuild of the implant pocket. Over four decades of breast surgery in Morristown, Dr. Rafizadeh approaches revision with a consistent set of tools, matched to the specific problem:
- Capsulorrhaphy — internal sutures that tighten and close off the parts of the pocket the implant has stretched into (the lower pocket in bottoming out, the midline in symmastia, the outer pocket in lateral displacement).
- Fold release or reconstruction — releasing a tight fold or rebuilding a stretched one, which is central to correcting a double bubble.
- Implant exchange — switching to a smaller, lighter, or more appropriately shaped implant so the tissue is no longer overloaded.
- Internal support — where tissue is thin or the repair is under tension, an acellular dermal matrix or surgical mesh reinforces the rebuilt pocket while it heals.
- Breast lift (mastopexy) — added when loose skin is part of the problem.
The mistake in revision is trying to fix a position problem by just changing the implant. If the pocket that let the implant drift is still there, the new implant will drift too. The durable fix is to rebuild the pocket — tighten what stretched, release what was too tight, and match the implant to the tissue.
For women who would rather move away from implants altogether, malposition is also a reason some choose breast implant removal, with or without a lift. Every path is planned individually during a consultation.
Why Technique — Not Just a New Implant — Determines the Result
The biggest predictor of a lasting revision is whether the underlying pocket problem was corrected. Simply exchanging the implant, or adding a larger one to “fill out” a bottomed-out breast, tends to accelerate the same failure. Rebuilding the fold and pocket with secure internal sutures — reinforced when the tissue is thin — is what keeps the implant where it is placed. This is why an experienced revision surgeon’s plan looks so different from a first-time augmentation.
Dr. Rafizadeh has performed breast surgery in Morristown for more than 40 years and sees revision patients from Summit, Chatham, Madison, Short Hills, Bernardsville, and across Northern New Jersey — as well as from Manhattan, Bergen County, and beyond. Out-of-town patients can read about travel arrangements on the out-of-town patient page.
When to Have a Position Change Evaluated
Any of the following after a breast augmentation is worth a call to your surgeon:
- The implant appears to be sitting lower than it used to, with a flat or empty upper breast.
- The nipple has started to point upward.
- A second crease or “line” has appeared across the lower breast.
- The implants have drifted toward the middle (loss of cleavage gap) or toward the sides.
- New aching, heaviness, or a dragging sensation in the lower breast.
Questions Patients Should Ask Any Plastic Surgeon in North Jersey
If you are researching breast implant revision for malposition in Morristown, Summit, Chatham, Madison, Short Hills, or anywhere in Northern New Jersey, the surgeon’s plan for rebuilding the pocket matters as much as the implant choice. Useful questions to ask:
- Which type of malposition do I have, and what is causing it?
- Will you rebuild the pocket with internal sutures (capsulorrhaphy), or just exchange the implant?
- Do you recommend a smaller or lighter implant to reduce strain?
- Will you use internal support such as a dermal matrix or mesh, and why or why not?
- Do I also need a breast lift to address loose skin?
- What can I do during recovery to protect the repair?
Common Questions Patients Search About Implant Malposition
Is a double bubble the surgeon’s fault?
Not always. A double bubble can result from surgical factors — an implant placed too low or a tight fold not fully released — but it also occurs because of a patient’s underlying anatomy, particularly a constricted or tuberous breast shape, or because the implant descends over time. In some cases it is a combination. What matters most is recognizing the cause so the revision addresses it, rather than assigning blame.
Can you fix a double bubble deformity without surgery?
A true double bubble caused by implant position or a fixed fold cannot be reliably corrected without surgery. Supportive bras or repositioning may mask a very mild case temporarily, but the crease returns because the underlying pocket and fold anatomy has not changed. Durable correction requires breast implant revision to release or rebuild the fold and adjust the implant. A consultation is the way to know which category you fall into.
Can a double bubble correct itself over time?
A very mild double bubble seen in the early weeks after augmentation can sometimes soften as the implant settles and swelling resolves. An established double bubble — a persistent second crease months after surgery — will not resolve on its own, because it reflects a fixed relationship between the implant and the fold. If it is still visible three to six months out, it should be evaluated for revision.
How do you fix bottoming out implants?
Bottoming out is fixed by rebuilding the lower pocket and inframammary fold. The surgeon places internal sutures (capsulorrhaphy) to close off the over-stretched lower pocket and raise the fold back to where it belongs, frequently combined with a smaller, lighter implant to reduce the downward strain. When the lower tissue is very thin, surgical mesh or a dermal matrix reinforces the repair so the implant does not descend again.
What causes breast implants to bottom out?
Bottoming out happens when the lower breast tissue or the inframammary fold cannot support the implant. The usual culprits are an implant that is too large and heavy for the tissue, a pocket dissected too low at the original surgery, naturally thin or weak tissue, and loss of elasticity over time as gravity pulls the implant down. Choosing an appropriately sized implant and precise fold placement are the best prevention.
Does breast implant bottoming out cause pain?
Bottoming out is more often a cosmetic and comfort issue than a painful one, but it can cause aching, a heavy or dragging sensation in the lower breast, and discomfort from the implant pressing against thin, stretched tissue. If bottoming out is sudden, painful, or accompanied by swelling or a change in firmness, it should be evaluated promptly to be sure another problem is not also present.
Frequently Asked Questions
What is breast implant malposition?
Breast implant malposition means the implant has moved out of its ideal position on the chest. It can sit too low (bottoming out), too close to the midline (symmastia), too far to the side (lateral displacement), or create a second crease across the lower breast (double bubble). Malposition is a shape and position problem — distinct from capsular contracture, which is a hardening problem. It is one of the most common reasons a woman seeks breast implant revision.
What is breast implant bottoming out?
Bottoming out is when the implant drops below the natural crease under the breast (the inframammary fold). The upper breast looks flat or empty, the nipple points upward, and the distance from the nipple to the fold becomes stretched and long. It happens when the lower breast tissue or the fold is too weak to hold the implant — often from an overly large implant, a pocket made too low, or thin tissue. It is corrected by tightening the fold and pocket, usually with a smaller implant.
What is a double bubble deformity?
A double bubble is when a second horizontal crease appears across the lower breast, so the breast looks like it has two bulges stacked on top of each other. It happens when the implant slips below the original fold while the fold itself stays fixed to the skin, or when a tight fold is not fully released. It is most common in women with a constricted or tuberous breast shape. Correction involves releasing or repositioning the fold and often adjusting the implant pocket.
What is symmastia?
Symmastia, sometimes called “uniboob” or “breadloafing”, is when the implant pockets meet in the middle of the chest and the implants drift toward the sternum, erasing the natural cleavage gap. It usually results from over-dissection of the pocket toward the midline or implants that are too wide. It is one of the more challenging malpositions to fix and is corrected by reconstructing the midline pocket wall, often with internal sutures or a supportive mesh, and sometimes a narrower implant.
How is breast implant malposition corrected?
Malposition is corrected with breast implant revision surgery that rebuilds the implant pocket. The surgeon tightens the parts of the pocket the implant has stretched into (capsulorrhaphy), releases the parts that are too tight, and often exchanges the implant for a size or shape that suits the tissue. In cases with weak or thin tissue, internal support such as sutures or an acellular dermal matrix / surgical mesh reinforces the repair. A breast lift is added when loose skin is part of the problem.
What causes breast implants to shift out of position?
The common causes are an implant that is too large or heavy for the tissue, a pocket dissected too low or too far toward the midline at the first surgery, thin or weak breast tissue, loss of skin elasticity over time, and gravity acting on the implant year after year. Trauma and capsular contracture can also pull an implant off position. Choosing an appropriately sized implant and precise pocket dissection are the best ways to prevent it.
Does Dr. Rafizadeh use mesh or internal support to fix malposition?
When the tissue is thin or the pocket repair is under tension, yes. Reinforcing a rebuilt fold or midline with internal sutures and, when needed, an acellular dermal matrix or surgical mesh gives the repair strength while the tissues heal — which lowers the chance the implant slips back into the wrong position. Whether support is needed is decided case by case based on tissue quality and the type of malposition.
How is malposition different from capsular contracture?
Capsular contracture is a hardening problem — the scar capsule around the implant tightens and squeezes it, making the breast firm and sometimes painful. Malposition is a position problem — the implant has moved too low, too close, or to the side, changing the breast’s shape. They can occur together, and both are treated with breast implant revision, but the surgical goal is different: softening and removing a capsule versus rebuilding and repositioning the pocket.
Related Reading From Dr. Rafizadeh’s Blog
Patients researching implant revision, positioning, and breast implant safety in Northern New Jersey may find these articles useful:
- Capsular Contracture After Breast Augmentation: Signs, Prevention & Treatment
- How Long Do Breast Implants Last, and When Should They Be Replaced?
- Breast Implants Over or Under the Muscle: Which Placement Is Right?
- Breast Asymmetry Correction: Options for Uneven Breasts
Bottom Line
An implant that has drifted too low, drawn a second crease across the lower breast, slid toward the middle, or fallen off to the sides is showing breast implant malposition — a position and shape problem rather than the hardening of capsular contracture. Each type has a defined cause and a defined fix, and the durable repair is always about rebuilding the implant pocket: tightening what stretched, releasing what was too tight, matching the implant to the tissue, and reinforcing the repair when the tissue is thin.
If you have noticed a change in the position or shape of your implants, or you are considering breast implant revision in Morristown, Summit, Chatham, Madison, Short Hills, or anywhere across Northern New Jersey, Dr. Rafizadeh is happy to examine you, identify exactly which type of malposition is present, and walk through your options during a consultation.
Sources & References
- Handel N. “The Double-Bubble Deformity: Cause, Prevention, and Treatment.” Plastic and Reconstructive Surgery. 2013;132(6):1434-1443. PubMed
- Spear SL, Little JW. “Breast Capsulorrhaphy.” Plastic and Reconstructive Surgery. 1988;81(2):274-279. PubMed
- American Society of Plastic Surgeons. “Seven signs you need a breast implant revision.” plasticsurgery.org
- American Society of Plastic Surgeons. “Breast Implant Revision.” plasticsurgery.org
- U.S. Food & Drug Administration. “Breast Implants — Risks and Complications.” fda.gov
- Dr. Farhad Rafizadeh, RealSelf Q&A profile. realself.com
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