What happened
Two studies have put a quiet complication of breast augmentation back on the table. A breast implant assessment clinic in Sydney prospectively evaluated 603 women with implants between 2018 and 2021: after capsular contracture and pain, the most common problems were two shape complications, the waterfall deformity and the double bubble, and the risk of a double bubble was roughly halved when the original surgeon was a certified practitioner (odds ratio 0.49). Then a 2026 comparison of 386 augmented breasts in the Aesthetic Surgery Journal reported a double bubble rate of 3.7 percent with the implant under the muscle (dual plane) and 0 percent with the implant under the fascia, on top of the muscle; lateral malposition followed the same pattern, 23.4 against 8.8 percent.
Neither finding is a verdict on a technique. Both say the same thing: the double bubble is not bad luck. It follows from how the lower breast is assessed and handled on the day of surgery.
The common misconception
Most patients who search for “double bubble” believe the implant has slipped or is faulty, and expect the fix to be a new implant. In a classic double bubble the implant is exactly where the surgeon put it. What creates the second curve is the patient’s own tissue: the original crease under the breast, the inframammary fold, is still there, drawn across the lower part of the implant like a tight band, so the breast shows one contour above the old fold and the implant shows another below it. It is a fold problem, not an implant problem, and swapping the implant without dealing with the fold brings the same shape back.
The clinical reality
The double bubble has a predictable anatomy, and it can be read before surgery. A 2021 study in Plastic and Reconstructive Surgery classified the inframammary fold of 2,192 consecutive augmentation patients into four types, from a fold that barely exists to a well formed, fixed fold that does not flatten when the arm is raised. Only three double bubbles occurred in the series, under 1 percent, and all three were in women with the fixed fold. A short distance between nipple and fold, a tight or constricted lower pole, or a broad base with a high crease raise the risk further. These are the breasts where a fuller lower pole requires lowering the fold, and lowering it without releasing the old one is how the second curve appears.
The implant pocket matters, and the muscle is part of the story. When the implant sits partly under the pectoral muscle, the lower edge of the muscle can act as a second band across the implant, especially when the breast tissue is thin. That is the most plausible reason the 2026 comparison found double bubbles only in the dual plane group. It does not make the dual plane wrong: under the muscle still gives thin patients more soft tissue cover and a smoother upper edge, which is why it remains the standard choice for them (the plane choice is explained on the breast augmentation page). It means that in a thin patient with a tight fold the surgeon has to manage the muscle edge and the fold deliberately, instead of hoping the implant will stretch them.
Prevention is a set of specific maneuvers, not a brand of implant. Neither implant profile nor surface prevents a double bubble on its own. Surgeons have published several ways of dealing with a strong native fold at the first operation: releasing the tissue just above the old crease so it cannot indent the implant, placing a little fat under the skin at the level of the old fold so the groove is filled, using a flap of deep tissue to blunt the fold and support the implant from below, or opening a third, more superficial layer in the lower pole of constricted breasts. A 2025 series of 46 women with a constricted fold treated that way reported a double bubble rate of 2 percent at one year. The techniques differ; the principle is the same. The old fold has to be dealt with on purpose.
In my practice the plane follows the tissue, and the fold follows the plan. I decide the implant plane by tissue thickness: under the fascia when the breast tissue is thick enough to cover the implant, dual plane under the muscle when it is thin, and never directly under the gland. When the native fold is tight or the nipple sits close to it, I release that fold during the operation rather than relying on the implant to flatten it, and I tell the patient beforehand that her anatomy carries this risk. In constricted and tubular breasts, where the lower pole is the whole problem, the implant is combined with release of the tight lower tissue, and I prefer the dual plane there.
The double bubble has cousins, and they are often confused with it. Bottoming out is the opposite problem: the implant slides below the fold, the nipple points upward and the lower pole becomes too long. The waterfall deformity comes years later, when the implant stays put under the muscle while the natural tissue sags off it, so the breast appears to pour over the implant; its repair is usually a breast lift over the implant, not a fold repair. Each looks like “two shapes” to the patient, but the causes and the repairs differ, and a photograph set from the front and both sides usually separates them before the consultation.
Correction is usually a smaller operation than the first, but it has to address the cause. In a true double bubble the repair means releasing or lowering the old fold properly, often reinforcing the new fold with internal sutures, sometimes changing the implant pocket, and in thin patients adding fat grafting over the groove. For context, a series of 1,707 augmentations reported an overall complication rate of 8.8 percent, double bubble among them: shape complications are uncommon, not rare, and they are treatable. The one thing that reliably does not work is changing the implant and leaving the fold exactly as it was.
The practical takeaway for patients
If you are planning a first augmentation, ask one specific question: how does my inframammary fold look, and will you need to lower it? A surgeon who has looked for a tight, high or short fold will answer in detail. If you already live with a visible second curve, do not rush into an implant exchange. Wait until the breast has settled, usually three to six months after surgery, because early swelling and a high riding implant can mimic a double bubble that resolves on its own. Then have the breast assessed for what it actually is: a tethered old fold, an implant that has dropped, or tissue that has sagged off the implant. The repair follows that diagnosis, not the search term. Front and side photographs with the arms down, then raised, show whether the groove deepens or disappears with movement, one of the clues that separates the three deformities.
Honest limits
The subfascial versus dual plane comparison is a single surgeon’s retrospective series, not a randomized trial, and surgeons who favor one plane select patients for it; a 0 percent rate in 194 breasts does not mean the subfascial plane is immune. The fold classification comes from the group that designed it. Prevention techniques are published mostly as technique papers with short follow-up, so none can claim to abolish the problem. And a second curve in the first weeks after surgery is often not a double bubble at all, which is why I do not offer a correction plan from early photographs. What the evidence supports without hedging is modest: the breasts at risk can be identified beforehand, the risk is lower when the fold is handled on purpose, and a repair that ignores the fold tends to fail.
If you have a second curve under your breast, or you are planning an augmentation and want to know whether your anatomy carries this risk, send photographs (front and both sides, arms down, then arms raised) to +90 544 772 0772. I review them personally, usually the same day, and tell you plainly what I see.
Dr. Mustafa Aydınol is a plastic, reconstructive and aesthetic surgeon in Istanbul and a member of ISAPS.
Sources
- Masoumi E, Seow C, Deva AP, et al. Prospective Study of Clinical Outcomes From a Breast Implant Assessment Service. 603 patients; most common complications capsular contracture, pain, waterfall deformity and double bubble; double bubble risk lower with certified practitioners (OR 0.49). Aesthetic Surgery Journal, 2023. doi:10.1093/asj/sjac266
- Gougoutas AJ, Gilson A, Check J, Movassaghi K. Subpectoral vs Subfascial Cosmetic Breast Augmentation: Are We Ready to Settle? 193 patients, 386 breasts; double bubble 0 percent subfascial vs 3.7 percent subpectoral; lateral malposition 8.8 vs 23.4 percent; capsular contracture 1.1 vs 5.2 percent. Aesthetic Surgery Journal, 2026. doi:10.1093/asj/sjaf210
- Phillips NA, Millan LS, Miroshnik M, Stradwick L, Layt C. A Novel Classification of the Inframammary Fold for Use in Primary Breast Augmentation. 2,192 patients; three double bubbles (under 1 percent), all in type F3 folds. Plastic and Reconstructive Surgery, 2021. doi:10.1097/PRS.0000000000008563
- Fertsch S, Wolter A, Rancati A, Angrigiani C, Voigt M, Andree C. Subcutaneous Lower Pole Release for Double Bubble Prevention in Constricted-Base Breasts: The “Plus One” Augmentation Technique. 46 patients; double bubble rate 2 percent; BREAST-Q satisfaction 43 to 94. Aesthetic Surgery Journal, 2025. doi:10.1093/asj/sjaf014
- Hoffman SW, Tavakoli K. The Inframammary Fold Effacement Flap for Strong Fold Breast Augmentation Patients. Technique paper on obliterating a strong native fold with an adipofascial flap and intradermal fat grafting. Plastic and Reconstructive Surgery, 2025. doi:10.1097/PRS.0000000000012358
- Garsten TA, Colpaert SDM. Double-bubble deformity in breast augmentation: correction with percutaneous barbed sutures. Technique letter, level of evidence V. Aesthetic Plastic Surgery, 2022. doi:10.1007/s00266-022-03086-0
- Montemurro P, Gupta T. Does the Surgeon’s Handedness Affect the Complications Rate in the Inframammary Approach Breast Augmentation? 1,707 patients; overall complication rate 8.8 percent including double bubble and bottoming out. Aesthetic Plastic Surgery, 2024. doi:10.1007/s00266-024-04372-9
- Kretsis V, Loizou CE, Kretsis K. Evaluation of a Technique to Minimize Complications in Breast Augmentation Surgery with Anatomical Implants: A Single Surgeon’s, 10-Year Experience. 622 patients; double bubble 0.16 percent, bottoming out 0.48 percent, rotation 0.8 percent. Aesthetic Plastic Surgery, 2025. doi:10.1007/s00266-025-05094-2
