Breast implant bottoming out occurs when the implant descends below the natural inframammary fold, causing the nipple to appear too high relative to the breast mound. The lower pole of the breast becomes elongated, and the implant may be visible or palpable below the crease. It is one of the most common malposition problems following breast augmentation.
The standard correction is a capsulorrhaphy — placing internal sutures to raise the lower boundary of the implant pocket, effectively recreating the inframammary fold at the correct position. Traditionally, this has required an incision in the breast crease, giving the surgeon direct access to place these sutures.
Endoscopic capsulorrhaphy offers an alternative: performing the same internal repair through the armpit incision, with suture placement guided by camera visualization instead of direct open access.
How Bottoming Out Happens
The inframammary fold is a natural tissue attachment that defines the lower boundary of the breast on the chest wall. During breast augmentation, the pocket is created to specific dimensions that respect this fold. Over time, however, the weight of the implant and the forces of gravity can stretch the lower capsule, allowing the implant to migrate downward.
Several factors increase the risk: heavier implants, subglandular placement (where the muscle does not provide a lower sling), thin tissue coverage in the lower pole, and incomplete capsule formation after the initial surgery.
The result is a breast that appears to have “fallen off” its intended position. Patients often describe it as the nipple pointing upward while the bulk of the breast sits too low.
The Endoscopic Capsulorrhaphy Technique
Through the original armpit incision, I insert the endoscope to visualize the interior of the capsule. The camera allows me to see exactly where the capsule has stretched and where the new fold needs to be established.
In mild cases, heating the capsule with endoscopic cautery is enough to make smaller adjustments.
In cases that need more adjustment, I use permanent or long-lasting absorbable sutures placed at multiple fixation points with evenly distributed tension. The goal is a durable repair that holds the fold position long-term, not a temporary fix that stretches out over months. Sometimes these sutures are placed endoscopically and in other cases, the sutures are placed percutaneously, through small needle holes that leave no scars. In all cases, the pocket for the implant is confirmed with direct endoscopic visualization.
After the capsulorrhaphy is complete, the implant is repositioned (or exchanged for a new implant), and the endoscope confirms that the implant sits centered within the newly defined pocket.
Published Evidence
Endoscopic capsulorrhaphy for bottoming out correction is described in the peer-reviewed literature. Published case series have demonstrated reliable correction of implant bottoming out after transaxillary augmentation using endoscopic suture techniques, including the use of barbed (V-Loc) sutures for capsulorrhaphy. Patient satisfaction in these series has been high, with durable correction and low rates of requiring additional surgery.
In my own published series of over 1,300 endoscopic transaxillary breast augmentations, malposition was the most common complication at 3.64%, and these complications were largely managed using endoscopic techniques — including capsulorrhaphy for bottoming out.
Who Is a Candidate
Endoscopic capsulorrhaphy for bottoming out is most appropriate for:
- Patients whose primary augmentation was performed through the transaxillary approach, providing an established armpit scar for re-entry.
- Bottoming out without concurrent significant skin excess or nipple ptosis (which would require a breast lift).
- Grade I or mild Grade II capsule condition — the capsule tissue needs to be healthy enough to hold sutures.
- Patients who wish to avoid a new incision on the breast.
When a Breast Incision Is the Better Choice
Severe bottoming out with very thin, attenuated lower pole tissue may not provide adequate capsule substance for a durable capsulorrhaphy. In these cases, reinforcement with acellular dermal matrix or internal mesh support may be necessary, and an inframammary incision provides better access for these materials.
If bottoming out is accompanied by significant breast ptosis requiring a mastopexy, the lift incisions on the breast are already part of the plan, making a separate discussion of armpit access moot.
Recovery
Recovery from endoscopic capsulorrhaphy is comparable to or easier than the original augmentation. Most patients return to normal daily activities within one week and resume full exercise within four to six weeks. A supportive compression garment is typically recommended for the first several weeks to support the new fold position while internal healing stabilizes the repair.
If you are experiencing implant bottoming out and want to explore whether endoscopic correction through the armpit is appropriate for your case, a detailed evaluation is the necessary first step.
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