Most patients that come to us to discuss Breast Revision surgery use one of three key words when describing their problem: “double bubble”, “waterfall”, or “bottoming out”. Sometimes it is the right term, sometimes not.

Since 2010 Dr. Agullo has responded to more than one thousand patient questions on RealSelf.com. Below are five (paraphrased for de-identification) from patients this year. His answers are below, lightly edited for the page. The full set of ten is on his surgical site.

“Have my implants bottomed out again? My nipples look high now.”

Answered on RealSelf, Jun 2026.

Breast bottoming out and high riding nipples are usually two descriptions of the same problem. The implant drops below the breast fold and takes the breast volume with it, which makes the nipple complex appear too high on the breast. This is very clear on your side photo as well where most of the breast volume is sitting low and the nipples are perched high. I do not know why your tissue failed the first time but by increasing your volume from 200cc & 250cc implants to 320cc & 350cc implants has likely contributed to your tissue failing a second time as the added implant weight can weaken an already compromised lower pole support. To correct this you will need to have a capsulorrhaphy performed to re-create your inframammary fold and raise your implant to its proper position. Because your tissue has failed twice already I would highly consider reinforcing your repair with mesh (GalaFlex, dermal matrix, etc…). I would also consider staying at your current implant size or possibly reducing the implant size slightly to reduce tension on the repair. Lastly, your nipples will correct themselves once the implants are raised back to their proper position. A lift revision, without moving the nipple, is likely necessary.

“Is this a double bubble, and can it be fixed without changing the implant?”

Answered on RealSelf, May 2026.

On your right breast yes I do think this could be corrected without having to exchange your implants. I am assuming that on the left side (which appears normal) your surgeon dissected the constricted old IMF scar line and performed a capsulorraphy medially. On the right side he/she most likely did not dissect the old IMF scar line down all the way which is now creating the horizontal fold inferior to the new IMF. In order to correct this your surgeon would need to go back in through your old incision and dissect this scar line down and perform a capsulorraphy to the breast implant pocket. This could potentially be reinforced with GalaFlex Lite to act as a hammock inferiorly to provide support and prevent recurrence. This does not appear to be an implant related problem as there does not appear to be any true implant bottoming out (implant pole inferior to the nipple). As long as this finding is confirmed to be true both standing and laying down on the right side this can be addressed with a capsule related procedure only and the implants left alone.

“My implants have slid out to the sides. Is that my chest or the surgery?”

Answered on RealSelf, May 2026.

You seem to have a couple things working against you here. The width of your chest wall and most likely overly aggressive dissection laterally by your original surgeon when creating the implant pocket. Wider set chest walls can make this deformity worse simply because there is more area laterally for the implant to fall into. I’m glad there is good cleavage when standing as that tells me this is not your anatomy but most likely due to your implant falling too far laterally within the implant pocket. I would most likely perform a capsulorraphy medially with permanent sutures to correct this deformity. I would most likely reinforce this with either P4HB or GalaFlex to prevent recurrence. If your implant base width is very wide I may consider implant downsizing as well. This would most likely correct your issue but sometimes subfascial implant placement can help as well in wide chested patients.

“Six months after augmentation with a small lift, what has gone wrong?”

Answered on RealSelf, May 2026.

What you’re experiencing is what is referred to as a “waterfall deformity”. Your implants are most likely in a good position but the tissue of your breast has fallen off of them inferiorly. This is what you’re feeling when laying on your side. This can be difficult to correct after augmentation especially if there was significant ptosis preoperatively as mastopexies (even donuts) do not always raise the breast tissue adequately over the implant. The only way to correct this would be with a breast lift (probably a large Benelli or true vertical/anchor mastopexy depending on the degree of ptosis) to raise the breast tissue back up on the implant. This can be combined with the use of mesh (GalaFlex Lite) to help maintain the implant shape.

“Saline implants for 25 years and a grade 3 capsule on one side. Will it come back?”

Answered on RealSelf, May 2026.

For your revision surgery ideally the entire capsule would need to be excised on the side with the contracted capsule (capsulectomy) and the implant placed in a new plane (dual plane or neo-subpectoral) on fresh tissue. Ideally the inferior portion of the pocket would be reinforced with acellular dermis (ADM) or synthetic mesh (GalaFlex Lite). With this strategy the reported rate of recurrence is in the single digits in most series. Without excising the contracted capsule and moving to a new plane on fresh tissue it is essentially a matter of chance.

Deflate and remove now, possibly reimplant later, versus exchange now

Both have their advantages and disadvantages. Deflating and removing your implants now and possibly reimplanting later would likely lead to a more challenging second surgery compared to a one stage exchange. The implant pocket will contract, your tissues will likely thin even further with no implant in situ, and ultimately a fat graft and possibly even a breast lift may be necessary prior to a new implant to optimize your outcome. Which strategy is best for you will depend on clinical exam and photographs taken at a consult visit.

The rule behind all five

Fix the pocket, back it up with mesh, and do not trust tissue that has already stretched once. A lift when the tissue has dropped, a pocket repair when the implant has moved, and the implant itself changed only when it is part of the problem.

Why choose Dr. Agullo

Dr. Agullo is certified by the American Board of Plastic Surgery and the American Board of Surgery, completed his plastic surgery fellowship at the Mayo Clinic, and serves as Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. He has been a Castle Connolly Top Doctor every year from 2014 through 2026. Breast revision is a large part of his 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 the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at agulloplasticsurgery.com/appointments. Dr. Agullo’s answers are also on RealSelf. #StayBeautiful

Find Dr. Agullo at @RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.