Can breast implants be placed to make my breasts look closer together?

While the issue of ‘over’ or ‘under’ the pectoralis major muscle receives a great deal of attention, even more important than implant position relative to this muscle is implant position vertically and horizontally on the chest wall.  In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness.

In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that an implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear ‘bottomed out’, with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast – another situation with a distinctly unnatural appearance.

The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Breast implant pockets that extend too fat laterally will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart.  If the pockets do not extend far enough laterally, however, the result is an augmentation with an abnormal ‘side by side’ appearance. As it is the lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an ‘hourglass figure’, careful attention must be paid to ensure that lateral breast projection is adequate and appropriate.

Another consideration is that the implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient who is 5’2” will be inadequate for a large-framed patient who is 5’10”. Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast enhancement.

Michael Law MD

Board certified Plastic Surgeon

Raleigh, North Carolina

In general, you can get more definitive cleavage with implants placed on top of the chest muscles. This is somewhat dependent on what amount and distribution of natural breast a person has to begin with. With the size of your breast you describe, any cleavage in you would come form the size and type of implant.However, you shouldbe aware that breast augmentation is an imperfect operation and you have to be able to accept certain imperfections, otherwise you can end up chasing the imperfections.

While you might be able to increase cleavage with wider implants or by releasing the muscles more aggressively near the sternum, both can have detimental effects. These effects should be fully discussed wth your plastic surgeon. In general, the more you go outside the natural dimensions of your native breasts, the more side effects and long-term complication you might have with rippling, palpability, tissue atrophy, asymmetry, and displacement of the implants. Sometimes, it is better to accept the limitations of your natural anatomy.  

When placing implants underneath the muscle, your surgeon must take great care to dissect the muscle properly to create the right cleavage. If the muscle is not released adequately, you will end up with a very wide space in between the breasts. If it is released too much, you can end up with synmastia, or a "uniboob" as some patients may call it.

To correct the wide space, you may want to consider a slightly larger implant, with a wider base. Your surgeon could increase the release area in the cleavage to improve the appearance. If the breast is really hanging low, the surgeon may recommend a mastopexy or lift procedure to correct the overall shape. This may require an additional incision around the areola or a larger incision on the base of the breast.

Either option may help you look more perky in your frame.

When breast implants are placed behind the muscle, the surgeon must do a good job of releasing the muscle fibers from the border of the sternum (breast bone) in order that the implant pockets are as close together as desired.  The surgeon must also avoid opening the pockets too far laterally (towards the armpit), as this will also make the implants look even further apart, since the tendency with the implants placed behind the muscle is for the muscle to push the implants downwards and outwards.  The pocket dissection must be precise, because if the muscle is released too far off the sternum, it can create a condition called "synmastia" where the breasts appear joined together across the midline of the chest, which can be very difficult to correct.

The problem of excessive cleavage width after sub-muscular implant placement can be corrected by placing an implant with a wider base diameter.  However, a wider implant alone will not correct the problem if the pocket dissection has been inadequate near the breast bone, or excessive laterally near the armpit, and these problems from the initial surgery must be corrected to attain a better result.

Implants are available in a variety of profiles (diameter vs. projection height) for a given volume in cc's.  To keep the same projection, you would need to choose a larger cc volume.  However, larger implants in general (above 350-400cc) may create problems of their own by causing the breast to "bottom-out" and sag.

Your surgeon should be able to discuss the options and trade-offs available to you to correct this problem.

The only way to get the implants to look closer in the midline is to use ones that are wider than what you have.  You might want to consider this in addition to maybe going down to a moderate plus profile so your breasts don't end up looking unnaturally large.

There are a couple of things to consider in order to get the cleavage right:

1. Most important I think is base diameter, so that there is the optimal space between the breasts while centering the implants in the natural foundation of the breast. With the right implant dimensions, some improvement can be acheived while still keeping the implants under the muscle.
2. The other issue is cohesive implants, which are shaped rather than round, and firmer than other silicone implants (which are also "cohesive" but softer). Because the round implants are not as stiff, they will move together more with pushup bras and bikini tops.