Augmentation in Ptotic and Densely Glandular Breasts: Prevention, Treatment,
and Classification of Double-bubble Deformity
Massiha, M.D., F.A.C.S.
From Louisiana State University School of Medicine, New Orleans,
Received Sep 3, 1999. Accepted for publication Sep 6, 1999.
augmentation, separation of breast tissue from the implant is common,
in patients with well-formed preoperative breasts.
This problem is enhanced to a marked deformity in cases of scar contracture
with firm, fixed implants. This paper addresses this problem preoperatively
and therapeutically in secondary correction of double-bubble and
waterfall deformity. The author classifies and explains double-bubble
in patients in whom the implant is below the normal crease, with
glandular breast tissue superior and anterior to the implant. In “waterfall” deformity
(a term suggested by the author), the glandular breast tissue droops
over the implant and is inferior and anterior to the implant. Treatment
used consists of opening the breast tissue from its posterior surface
using radial incisions to accommodate the implant. This allows the
two structures-the breast tissue and the implant-to blend as one
unit with satisfactory results. The technique is easy to perform
Complications are similar to those of regular breast augmentation.
Strangely, radial incisions have not increased complications, and
there have been no cases of seroma or hematoma to date.
are performed predominately in breasts that are originally flat
have very soft textured tissue. During the
dissection and creation of the pocket, this tissue opens adequately
to accommodate the round shape of the implant and, ultimately, the
two become one unit. However, in cases of extremely dense breasts
that are quite formed (usually with a small base), in cases of tubular
breasts, and especially in ptotic breasts, this natural unity does
not happen, resulting in a double-bubble deformity. This deformity
occurs because the implant stays firmly in the original area in the
chest wall while the breast tissue sags over it like a “waterfall” over
a rock. Conversely, in the case of very firm breasts, the implant
stays in place while the firm, highly glandular breasts stay up and
do not conform to the implant. In the last several years, I have
tried to remedy this problem by opening the breast tissue using radial
cuts from the inside at the level of the pectoral fascia to accommodate
the spherical shape of the implant. This procedure not only accommodates
the implant but also widens the base of the breast, which helps it
form better to the implant, enhancing the future shape of the breast.
Materials and Methods
Several categories of breast shapes may benefit from t