Breast implant malposition — an implant that is not sitting where it should — is the second most common reason for breast augmentation revision surgery, after capsular contracture. In my published series of over 1,300 endoscopic transaxillary augmentations, malposition was the most frequent complication at 3.64%.
Malposition presents in several forms, each with a different underlying cause and a different corrective approach. What these forms share is that many of them can be addressed endoscopically through the armpit incision when the surgeon has camera-guided visualization of the pocket interior.
Types of Implant Malposition
Superior Malposition (Riding Too High)
The implant sits higher on the chest wall than intended, creating an unnatural fullness in the upper pole while the lower pole appears deficient. The breast may look rounded at the top with a flat or empty lower half.
This typically results from incomplete release of the inferior pectoralis muscle attachments during the initial augmentation, or from capsular contracture pulling the implant upward. In the blind transaxillary technique, incomplete inferior release was a recognized limitation — and one of the reasons some surgeons moved away from the armpit approach. With endoscopic technique, the inferior release is performed under direct visualization, making it more complete and reducing the incidence of high-riding implants in primary surgery and enabling precise correction in revision.
Another scenario is when implants are placed under the muscle and the breasts droop with time. In this situation the implant appears too high and the breast sits lower on the chest, creating an unnatural appearance. Through an armpit incision, the implant can be repositioned to a new pocket above the muscle to resolve this issue.
Inferior Malposition (Bottoming Out)
The implant descends below the natural inframammary fold. This is discussed in detail in my post on endoscopic capsulorrhaphy. Correction involves raising the lower pocket boundary with internal sutures placed under endoscopic visualization.
Lateral Malposition
The implant shifts toward the armpit, widening the gap between the breasts and preventing cleavage even with a bra. This can result from lateral pocket over-dissection during the initial surgery or from asymmetric capsular forces pushing the implant outward over time.
Endoscopic correction involves placing capsulorrhaphy sutures along the lateral capsule wall, tightening the lateral boundary to push the implant back toward the midline. The endoscope provides direct visualization of the lateral capsule, enabling precise suture placement at the points of greatest laxity.
Medial Malposition (Symmastia)
Both implants migrate toward the center, eliminating the natural separation between the breasts. In severe cases, the implants can contact each other across the midline, creating a “uniboob” appearance.
Symmastia correction is among the most technically demanding revision scenarios. It requires re-establishing the medial pocket boundary along the sternum. In mild cases, endoscopic medial capsulorrhaphy through the armpit can achieve this. In more severe cases with significant medial pocket disruption, an approach providing direct access to the sternal attachments may be necessary.
Sometimes a switch in plane can help – switching endoscopically from under the muscle to over the muscle, or vice versa – over the muscle to under the muscle, with a completely new implant pocket can correct symmastia.
Why Endoscopic Visualization Matters for Malposition Correction
Every malposition correction involves the same fundamental task: changing the boundaries of the implant pocket so the implant sits in the correct position. This requires placing sutures in specific locations within the capsule to tighten areas that are too loose or releasing areas that are too tight.
Without visualization, this is guesswork. The surgeon estimates where the sutures should go based on external landmarks and tactile feedback. Results are variable.
With endoscopic visualization, I can see the capsule interior, identify exactly where the pocket boundary needs to move, place sutures at precise points, and confirm the correction visually before closing. The camera converts a judgment call into a measured procedure.
Results from Published Data
In my case series, malposition complications in endoscopic transaxillary augmentation occurred at a rate of 3.64%. This is within the published range for breast augmentation across all incision approaches, indicating that the endoscopic transaxillary technique does not carry a higher malposition risk than conventional approaches — contrary to claims sometimes made by surgeons unfamiliar with endoscopic technique.
Importantly, a significant decrease in malposition was observed in the subfascial placement group compared to submuscular, suggesting that pocket plane selection plays a meaningful role independent of incision approach.
Individual Evaluation Is Essential
Malposition correction is not a one-size-fits-all procedure. The type of malposition, its severity, the quality of the capsule tissue, and the patient’s anatomy all factor into the approach. Some cases are straightforward endoscopic corrections. Others require more extensive open revision.
A surgeon experienced in both endoscopic and open revision techniques can evaluate your situation objectively and recommend the approach most likely to achieve a lasting correction — whether that means preserving your scar-free breasts through the armpit approach or recommending a different path when the clinical situation calls for it.