The ‘waterfall effect’ is a descriptive term to indicate a sliding ptosis of parenchymal breast
tissue over a fixed or encapsulated implant. It occurs more frequently than surgeons anticipate and especially
over the longer term after augmentation. Certain breast implants are more prone to contribute to this
problem as are implants placed in submuscular pockets that ride high, especially in women with anatomical
musculoskeletal variance or asymmetry. This article describes the aetiology of sliding ptosis in more detail,
the relevant anatomy and the surgical correction. Understanding the problem enables the surgeon to plan
the appropriate procedure and obtain proper informed consent. It is possible that a two stage procedure
is necessary should the upper pole of breast require a debulk, either early (3 to 12 months) or later as the
breast may slide with ageing of the tissues. The waterfall effect of breast parenchyma over implants is only
apparent when the upper torso of the woman is undressed and she is in an erect posture. A significant
number of women are happy with this situation and therefore no further action is required. Those that want
an improved appearance in these circumstances can try autologous fat transfer to rebulk the surrounding
tissues but generally the most likely solution involves a mastopexy with or without implant exchange. The
results are highly rewarding but the scars are the legacy. Mastopexy augmentation is a difficult procedure and
should only be performed by experienced surgeons. Many surgeons prefer a two stage approach with either
an implant based augmentation first to limit scars and see if the patient is happy with the outcome or a first
stage mastopexy to decide whether implants or fat graft are actually required as a secondary procedure
