Breast augmentation is often talked about as if everyone starts from the same “blank canvas”. In real life, many patients have subtle (or sometimes obvious) differences in the shape of the chest wall that can affect how implants sit, how cleavage forms, and how symmetrical the final result looks. We see many patients with vary degrees of chest wall deformities and many patients were not aware they had them.

These chest wall differences are common. Studies of augmentation patients have reported chest wall deformities in roughly 1 in 10 patients (and in some reports higher, depending on definitions and how carefully measurements are taken). 

The good news is: breast augmentation can still be very successful in patients with chest wall deformities, but it usually needs more planning, more measuring, and more honest discussion about what is—and isn’t—achievable.

What counts as a “chest wall deformity” in breast augmentation?

When surgeons talk about chest wall deformities in this context, they usually mean structural differences of the sternum, ribs, spine, or chest muscles that change the foundation the breast sits on. Common examples include:

• Pectus excavatum (sunken chest / dipped sternum)
• Pectus carinatum (pigeon chest / protruding sternum)
• Rib flaring or rib asymmetry
• Spinal curvature (scoliosis) affecting rib cage alignment
• Poland syndrome (underdevelopment/absence of pectoral muscle with breast/chest asymmetry)
• General chest wall asymmetry (one side more prominent or flatter)

It’s also important to separate chest wall deformities from breast developmental differences (like tuberous breasts). In practice, they often overlap—patients can have both breast and chest wall asymmetry, which is why careful assessment matters. 

Why chest wall shape matters for implants

Implants don’t sit “in the breast”—they sit in a pocket on the chest wall (either under the gland, under the fascia, under the muscle, or partially under muscle depending on technique). If the chest wall is uneven, then:

• The same implant can look different on each side.
• The nipple position may look more uneven after surgery (even if it was subtle beforehand).
• Cleavage can appear too wide or too close.
• Implant edges may be more visible on one side.
• The risk of malposition (implant sitting too far in/out or too high/low) can be higher.

One key concept: you can make the breasts more symmetrical, but you can’t fully “erase” the underlying skeleton with implants alone in every case. Some patients benefit from additional techniques (fat grafting, pocket adjustments, or even custom chest wall implants in select situations). 

How common are chest wall deformities in augmentation patients?

Rates vary by study and by how strictly “deformity” is defined. In one clinical series of cosmetic augmentation patients, chest wall deformities were found in about 10.6% of patients, with pectus excavatum being the most common deformity in that group. 

More recent discussion in aesthetic literature highlights that chest wall/breast asymmetries are frequent in cosmetic practice and that reported rates can be higher in some settings. 

In other words: if you feel like your chest wall isn’t perfectly symmetrical—you’re not alone.

The most common chest wall deformities and what they mean for breast augmentation

Pectus excavatum (sunken chest)

What it is: The sternum sits more inward than usual, creating a central dip. This can be mild or more pronounced. 

How it affects breasts/implants:

• Cleavage can look “wide” because the midline is recessed.
• The breasts may appear to point outward slightly.
• One breast can look smaller or sit differently because the chest wall under it is shaped differently.

Surgical strategies that often help:

• Careful pocket positioning to control implant direction (avoiding implants drifting too far outward).
• Implant shape/profile selection to balance projection and width.
• Fat grafting along the inner breast or sternal border in select cases to soften the dip (where appropriate and safe).
• In more complex asymmetry: 3D planning and staged strategies may be useful. 

There’s also published work specifically assessing breast augmentation approaches in pectus excavatum patients aiming to improve both breast shape and the appearance of the deformity. 

Pectus carinatum (pigeon chest)

What it is: The sternum protrudes outward, sometimes with dips on either side.

How it affects breasts/implants:

• The sternum can dominate the profile view.
• Cleavage may be harder to create naturally because the midline is prominent.
• Implants that are too wide can exaggerate the “bowed” appearance.

Surgical strategies that often help:

• Thoughtful implant selection (often avoiding overly wide implants that emphasise the central prominence).
• Pocket design to help the breasts frame the sternum rather than highlight it.
• Sometimes higher projection can visually balance the sternum (this must be individualised). 

Rib flaring, rib asymmetry, and “uneven foundations”

These can be subtle yet very impactful. One rib cage side may be more prominent, flatter, or angled differently.

Practical consequences:

• The IMF (inframammary fold) can be naturally higher on one side.
• One implant may look like it sits “wider” or “higher” even if the implants are identical.

Common solutions:

• Precise pre-op measurements and marking (often more extensive than a standard case).
• Deciding whether to:
  • keep implants the same and adjust the pocket, or
  • use small implant differences only if truly needed.

A key modern principle is not to “chase perfection” by using dramatically different implants to compensate for a skeletal problem—this can create new issues long-term. Some authors advocate treating the chest wall issue and the breast augmentation as related but distinct problems, sometimes using staged or adjunctive approaches. 

Scoliosis and spinal curvature

Scoliosis can rotate the rib cage, affecting breast position and chest projection. Patients may notice one breast sits higher or the nipples don’t align horizontally.

Surgical planning considerations:

• Acknowledging that the torso itself is rotated or tilted, which affects how “level” breasts appear.
• Sometimes aiming for “best visual symmetry” rather than strict measurement symmetry (because the body isn’t symmetric).

Poland syndrome and chest muscle differences

Poland syndrome classically involves underdevelopment or absence of the pectoralis major on one side, often alongside breast and rib differences.

Why it’s different:

• The muscle is part of the implant pocket and influences implant coverage and movement.
• The nipple/areola and breast tissue can also be underdeveloped.

Options may include:

• Implant-based reconstruction principles (often more complex than routine cosmetic augmentation).
• Fat grafting to improve soft tissue coverage.
• Sometimes staged surgery.

These are highly individual cases and benefit from careful counselling and planning. 

The consultation: what should be assessed

In chest wall deformity cases, the pre-operative assessment is everything. A thorough consultation commonly includes:

• Full breast measurements (base width, nipple-to-fold distances, sternal notch-to-nipple, etc.)
• Chest wall and sternal assessment (including midline position)
• IMF level differences
• Skin quality, stretch marks, tissue thickness (pinch test)
• Photographs from multiple angles

Clinical research in augmentation patients with chest wall deformities stresses the importance of meticulous evaluation and measurement because implant choice and pocket planning may need to change depending on deformity pattern. 

Implant and technique choices that often matter more in chest wall deformities

Implant width and base diameter

Choosing implant width to match the breast footprint becomes even more important when the chest wall is uneven. Too wide can worsen asymmetry; too narrow can look unnatural.

Implant projection (profile)

Projection can help balance a depressed or prominent sternum in some patients, but it’s not a universal rule. The goal is harmony from the front and side, not just “bigger”.

Implant placement (over vs under muscle)

• Submuscular / dual plane placement may provide better coverage in thinner patients and can help control upper pole shape.
• Subglandular placement can work well in patients with adequate tissue but may reveal asymmetry more clearly if the chest wall is uneven.
• Some cases may benefit from fascial techniques depending on anatomy.

The “best” choice is anatomy-led, not trend-led.

Pocket control and internal shaping

Small differences in pocket dissection can strongly influence symmetry:

• Medial release to improve cleavage must be balanced against the risk of implants sitting too close (symmastia).
• Lateral control can prevent implants drifting outward, which may be more likely with some chest wall shapes.

Fat grafting as an adjunct

In selected patients, fat transfer can smooth transitions and camouflage chest wall dips or implant edges. It’s not a replacement for good implant planning, but it can be a useful finishing tool.

3D planning and custom approaches

There is increasing interest in 3D simulation and planning for complex asymmetry cases, including pectus excavatum-related deformity and breast asymmetry. 

For some patients with significant chest wall contour issues, specialist centres also discuss custom chest wall implants (separate to breast implants) using modern imaging/modelling workflows. 

What results can you realistically expect?

Most patients with mild-to-moderate chest wall deformities can achieve a substantial improvement in breast shape, size, and symmetry, particularly when the plan is tailored.

However, it’s important to understand:

• Perfect symmetry is not a realistic goal for most humans, even without a chest wall deformity.
• Surgery improves appearance in clothing and out of clothing, but certain angles/lighting may still reveal differences.
• If the rib cage or sternum is significantly asymmetrical, implants alone may not completely mask that in every posture.

Risks and complications: what to watch for

Breast augmentation always has risks; chest wall deformities can shift the balance of certain risks, including:

• Implant malposition (too lateral, too high, bottoming out)
• Visible rippling/edge visibility if soft tissue coverage is thin
• Persistent asymmetry despite best efforts
• Capsular contracture (risk varies and is multifactorial)
• The need for revision surgery (sometimes for refinement)

When to consider staged surgery or additional procedures

You might discuss staged or adjunctive approaches if:

• asymmetry is moderate-to-severe
• nipple position differences are significant (may need a lift on one side)
• chest wall contour is a dominant aesthetic issue
• soft tissue is very thin and would benefit from fat grafting before or after implants

Some recent surgical discussion emphasises separating the chest wall correction conceptually from augmentation goals rather than trying to compensate for everything with very different implants. 

FAQs

Can breast augmentation “fix” pectus excavatum or pigeon chest?

Breast implants can improve the overall look by enhancing breast volume and helping balance the chest visually. They do not change the bones. In some patients, the chest dip or prominence remains noticeable—just less dominant.

Will I need different sized implants on each side?

Sometimes, but not always. Many patients do better with the same implant and a tailored pocket, or only small implant differences. The decision should be based on careful measurements and what is driving the asymmetry.

Is fat grafting safe with implants?

In appropriately selected patients and performed properly, fat grafting is commonly used to refine contour. It has its own risks (lumps, fat necrosis, unpredictable take) and should be discussed clearly.

Do I need a CT scan or 3D imaging?

Most cosmetic augmentation patients don’t need CT. For complex chest wall deformity cases, some surgeons may use advanced imaging or 3D planning to improve accuracy. 

Conclusion

Chest wall deformities are not rare in breast augmentation patients, and they’re one of the most important reasons why two “identical” augmentations can look completely different from one person to the next. Good outcomes come from:

• recognising the deformity early
• measuring properly
• selecting implants that suit the breast and the chest wall
• controlling the pocket to guide implant position
• using adjuncts like fat grafting or advanced planning when needed