350cc & 450cc, pectoralis muscles too tight, could we revise the size of smaller implants? (Photos)

Using different size implants for asymmetry is a very tough game to get right. But I agree the size difference is too great and changing the size of one of the implants does make sense. If you were my patient I would let you make the decision regarding size change.

When I started out as a plastic surgeon and I had a patient with asymmetry I used to always place different sized implants like you had done. What I found over time is exactly what you have experienced. Over time, 6 months to 24 months what happens is the larger implant becomes noticeably larger. I say the implant always wins in the end, meaning that eventually it is the implant that becomes the dominant component of the breast and then implants that were placed to correct asymmetry actually generate MORE asymmetry.

Today I still use different sized implants in patients with notable asymmetry, but I keep the implant sizes much closer together in size, say 25 cc or 50 cc and not go for the 100 cc difference as I know with time we will have reversed the problem in that the originally smaller breast will now look markedly larger if I use markedly different implants. In other words, the patient will now see the asymmetry in the implants which is usually more pronounced than the original asymmetry.

For patients that have a normal amount of asymmetry, not something that really stands out, but a little asymmetry (super common), then I use the same sized implants in each breast and I explain to the patient before surgery that there will be a little asymmetry as she has now but that it is better than if I put different sized implants and she will see the different implant sizes in a year. Most people understand this and are happy to accept a little normal asymmetry rather than be left with one large breast and a smaller one.

if the muscle is too tight for placement of the implants then it might be a good option to place them over the muscle. I prefer subfascial for this. If you had dual plane under muscle, then the muscle should be re-attached where it was cut. Fine-tuning the implant size for better symmetry might be easier with over muscle/subfascial, but there may be other things to consider.