Breast Implants: Large Pocket vs. Small Pocket?

I recently noticed that surgeons have different preferences when it comes to breast implant pocket size. Observing photos, I notice that generally the implant sits quite high post surgery and drops over over time. My friend got implants and they were never high. They looked great from day 1. Her surgeon said his patients don't need to wait for implants to drop. He mentioned that other surgeons create a larger pocket. Why would a surgeon prefer a small pocket over a large one?

Doctor Answers 13

Breast Implant Pocket Position

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In many breast augmentation 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. Ideally the implant should be centered directly behind the nipple-areola complex (NAC). 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 a breast implant sits below the skin. In addition, inadequate release of the inferior origin of the pectoralis major will allow the muscle to hold the implant in too high a position, and may even cause the implant to displace upwards (as high as the collar bone in some patients) when the muscle contracts. Patients with this problem require reoperation to release the inferior origin of the pec major and/or the inframammary fold.

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, and one that requires surgical correction: repair of the inframammary fold(s).

The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Excessive lateral dissection of the implant pockets 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. The result may (or may not) be tolerable in the upright standing or sitting position, but when the patient lays down in supine position (on one's back) the implants may fall far to the side and produce little to no anterior breast projection in this position. Patients with the problem almost always want it corrected, and the treatment once again is surgical: a lateral repair of the implant space, to restrain the implants from falling off to the side.

Inadequate lateral dissection, on the other hand, will result in an augmentation with an abnormal 'side by side' appearance. It is lateral projection of the breasts beyond the lateral border 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'. While one does not want to over dissect the lateral extent of an implant pocket, careful attention must also be paid to ensure that lateral breast projection is not inadequate.

Breast implant base diameter is also of crucial importance. The base diameter (the side-to-side dimension of the implant) must be ideal for the existing horizontal dimension of the breasts preoperatively, as well as the breadth of the anterior chest in general. Obviously, a given implant volume and base diameter that works well for a small-framed patient that is 5'3" will be completely inadequate for a broad-chested patient who is 5'10". One wants to increase cleavage area fullness and lateral breast projection in most cases, and an implant of inadequate base diameter may accomplish only one of those goals, while too wide an implant will be overprojecting in both directions. Careful evaluation of all of these breast and implant dimension issues is necessary if the ultimate goal of the surgery is a natural-appearing breast augmentation.

Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Breast augmentation

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There are many factors that determine how your breasts will look right after surgery. If you have small breasts with tight skin , aren't very tall or if you are going fairly large it is more likely you will have a high type of look. If your breasts are at least a B cup or greater , if they are a little loose from having children , if you are tall and a lot of space on your rib cage , or if you aren't going very large they might look very natural right from the beginning. The profile of the implant you choose will also affect the look. No two people will have the same look even if you put the same implant in. So to compare yourself to a friend's experience doesn't really make sense. And as great as her surgeon may make himself / herself sound I'm sure he / she has had implants that looked a little high at first.

David E. Kim, MD
Beverly Hills Plastic Surgeon
4.6 out of 5 stars 106 reviews

Size of pocket

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The size of pocket is based on the size of the implant, the type of the implant and the experience of the surgeon.  Long term follow-up is so important so a surgeon can get a good idea of the long term outcome of his/her approach.  I always encourange my patients to come back yearly so I can get this followup. 

My current approach with smooth implants is to make the pocket just a little bigger than the implant and get the patient massaging the breasts within a week.  I follow my patients closely for the first few months because sometimes they loosen up too much and I have them back off on the massage.  There are so many variable in this operation, that one approach for all patients can't possibly be right.  This is the art and "practice" of plastic surgery.  I am always learning!

Lisa Lynn Sowder, M.D.

Lisa Lynn Sowder, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 77 reviews

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Pocket size in breast implant augmentation

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This is a very perceptive question and is one of the keys to understanding how surgery, implants, and results work. There are actually two issues. One is pocket size relative to the implant size and the other is the position of the implant relative to the breast. 

If you think of it as an orthopedic surgeon putting in a hip implant it's easier to understand. The "pocket" for the implant has to be precise and the size of the implant has to exactly fit the "pocket" in the bone and then it has to heal there. It's not as exacting in a breast implant and the tissues are more forgiving of errors in sizing and positioning, but the principles are the same if a predictable, controlled result is desired and expected. 

There was a theory in breast augmentation that if the pocket was made bigger and the implant was significantly smaller than the pocket that this would avoid or prevent capsule contracture (a condition where the capsule of scar tissue around the lining of the pocket becomes too small for the implant). This turned out to have little to do with capsule contracture and a pocket that was too big for the implant could result in the implant not ending up in the correct position relative to the breast. It also makes no sense to place an implant in the wrong position such as "too high" and then hope that it heals or ends up in the correct position. 

An experienced breast augmentation surgeon with consistent results will make a pocket in the correct position relative to the breast and place an implant in it that fits it and then get it healed there (with the patient's help postoperatively). Unless the implant was too big for the pocket or was placed too high at the surgery, it's an illusion that it starts out too high and then drops into the correct position. The reason it appears that way is that the lower pole of the breast has the most stiffness and reaction compared to the upside so it appears that the implant is too high but "drops" as the stiffness in the lower pole resolves. This is like differential swelling around other surgical areas including procedures like liposuction. The apparent distortion resolves as the tissues recover. The implant should start in the correct position and stay there.

Scott L. Replogle, MD
Boulder Plastic Surgeon

Do breasts look the same after dropping?

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Two things happen and seem paradoxical. As as the swelling goes down there will be some shrinkage but at the same time as the muscle relaxes your breast projection grows. In general the breast shape and size proportionality improves..

Breast implants initially after surgery when placed in a submuscular position often give superior fullness that corrects itself with time, the "fluff and drop" phenomena. In reality the pectoralis major muscle takes a while to adjust its size to accommodate the implant as well as occasional muscle spasm which keeps the implant projection higher than its final resting shape. Additional variables include:laxity of skin, size difference during prior pregnancies, position of implant,size of muscle, and size of implant.
As the muscle relaxes the projection of the implant often increases and the breast shape improves. Massage and use of a superior placed elastic strap can often make this process go faster.

Breast pocket size and breast augmentation

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Breast pocket size is determined by a number of factors - the size of the patient's chest, the size of the implants being used, the elasticity  of the skin and breast tissue, etc.  In this regard, most plastic surgeons adopt the Goldilocks approach - not too big and not too small, but just right.  Given the number of variables, there is no exact or "right" answer.  If one has tight tissues and/or small breast and chooses large implants they will be tighter and sit higher on the chest regardless of how big the surgeon tries to make the breast pocket. 

Vincent D. Lepore, MD
San Jose Plastic Surgeon
4.7 out of 5 stars 63 reviews

Pocket Control in Breast Augmentation Matters

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Dear CanadianGirl26,

In breast augmentation, an important part of the surgeon's job is to choose a suitable breast implant and to create the proper space (or "pocket") for that implant to sit in. In general, the pocket should be neither too small (which can distort or constrict the implant) nor too large (which can lead to implant migration or malposition). The pocket needs to be "just right," which is why choosing a skilled surgeon is important. In general, most implants drop a little bit or settle in after surgery.

Warmest wishes,

Larry Fan, MD

Larry Fan, MD
San Francisco Plastic Surgeon

Breast Implants - High Post-Op, Need to Settle

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Hi CanadianGirl26 in Vancouver, BC,

As always, there are many different answers to a question such as this.

But I would say that, in general, most surgeons make the pocket approximately the correct size and location to fit the desired implant, and centered under the nipple.  Years ago, when it was felt that implants needed to be massaged around a larger pocket to prevent capsular contracture, surgeons would be more likely to create a large pocket to begin with.   With submuscular implants that is no longer described to the same degree.

On the other hand, implants often appear high after the surgery and then "descend" over the subsequent weeks.  In general, and implant is more likely to be held "high" when it is relatively large compared to the pocket.  When you're getting two different size implants - because one breast is larger than the other - it's a little more likely for the implant that is larger (and therefore in a tighter pocket) to take a little lower to drop.

As the muscles relax to accommodate the implants, they typically drop into place.  From the outset, though, they are less likely to be pulled high if they are relatively small and in a pocket that is relatively loose.

I hope that this helps, and good luck,

Dr. E

It should be about the size of the implant

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The pocket should be created to be about the size of the implant - too large a pocket will let the implants fall to the side when you lay down, too small and the implant will get squished and look funny at first.  Most people's implants look high at first but sometimes the inflammatory reaction is less and they don't look too high - I find this happens more with silicone implants.  This may be what was going on with your friend.

Implant position

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Implants change position a bit with time.  They can initially be pulled up by the muscle from spasm after srugery.  It really has nothing to do with the pocket size because under the muscle, the implants can be "pistoned" by the muscle which can cause the pocket to open up in the natural plane.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.