What is a Double Bubble after Breast Augmentation?
A double bubble is the term used to describe the unwanted appearance of a double curve in the lower half of the breast after breast augmentation, as seen when looking at the patient from her side and with the patient stood upright. It can occur just on one side or it can affect both breasts. It can be very subtle or be very obvious depending on the severity of the problem.
What causes a double bubble breast abnormality?
It is caused by the lower edge of the breast implant being below the pre-existing natural crease that is under the breast. The natural crease is called the infra-mammary fold (IMF). The IMF is a physiologically tight area of condensed tissue layers that defines the transition between the breast and the abdominal wall skin and fat layer. It is sometimes noted surgically as a narrow area of about 5-10mm of slightly white thin fibrous tissue (fascia) that runs across the crease line. In some women who are particularly flat chested the lower crease is very poorly defined or cannot be defined at all. Sometimes the whole of the lower breast seems to be just skin adherent to the underlying chest wall, as if the the fibrous area extends abnormally. This more extensive appearance can be a transition into some of the developmental abnormalities that some women have and is termed a constricted breast. The problem with these starting points is that this tissue is tight and relatively inelastic. If the upper breast stretches more easily over the implant and this lower part doesn’t, it will create a visible transition line where the tighter tissue old passes over the curve of the implant. Sometimes the lower edge of the implant needs to be lower than an unnaturally high IMF, and the lower edge of the implant that is just beyond the IMF therefore bulges into the tissue beyond the IMF as it is slightly more stretchy. The upper curve is the natural line of the breast over the implant, and the smaller lower bulge is the unnatural part that falls below the old IMF. Hence the double bubble description.
How to prevent a double bubble?
The first way is for the surgeon is to spot, through careful assessment, who is at risk and to discuss this at the consultation. I would estimate that with correct implant planning the risk is less that 5%. It may be possible to choose a smaller implant and to lower the risk. Otherwise, steps can be taken during surgery to finely score through the tight tissue bands using a scalpel. The has to be done very carefully and the surgeon needs to be experienced with the technique. This can can help to restore some tissue stretch allowing the skin to conform to the lower edge of the implant without a band forming. The IMF is then re-defined by the deep sutures as used with the surgical closure technique.
What is the Shoelace Technique to treat a Double Bubble Breast Appearance?
This is a novel technique described in the Aesthetic Surgery Journal in July 2014 by Daniel Mills. It involves the post operative application of an external support fashioned around the breast using two 54-inch flat shoelaces that are 3/4 inch broad. They are tied in a novel way such that they provide a tight definition to where the surgeon wants the IMF to actually lie. It is obviously only applied when the surgeon sees a double bubble appearance forming. It is worn by the patient sometimes on its own or sometimes with an under-wired bra. The author uses it for around 3-weeks. It is not useful in treating old double bubbles that have formed, as it is then too late to be beneficial.
How often has this been used?
In the author’s report he states that he has used it over 200 times. This is interesting as I have not seen a double bubble appearance except in a handful of occasions in over 15-years performing breast augmentation. So prevention in the planing phase and intra-operatively is probably an important element here. But if it were to occur, then knowing about the shoelace breast cast as described by this author is valuable,