Breast Implants: Large Pocket vs. Small Pocket?

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.

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 implants always drop over time unless they are held up by a submuscular position.  "High" implants can be due to post-surgical swelling that is more prominent up on top and resolved w time.  "High" implants are normal when I perform the transaxillary approach as the pectoral muscle take some time to relax and the implant descends a little.

When implants are place above the muscle they ALWAYS drop over time and I slightly overcorrect for this by initially placing them higher.  Over the following three months they settle in and look great.

Sincerely,

Martin Jugenburg, MD

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.

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.