Surgical Planning

Breast Augmentation with Pectus Excavatum

UNE Plastic Surgery · Dr. Kim Uigeon, board-certified plastic surgeon · Published 2026-09-21 · Updated 2026-09-21

1. Five findings that accompany pectus excavatum

These are checked alongside — looking only at the breast misses parts, so the whole chest is assessed. Analyzing 11 patients (women, 21–39), Moscona & Fodor described five anatomical features directly (Moscona & Fodor, Aesthetic Plastic Surgery, 2011).^[1]

• Sternal depression: the paper describes a “deformed sternal area,” the sternum deformed inward.
• Chondrocostal junction depression: an abnormal depression of the costal-cartilage area identifiable by preoperative chest palpation, deep in some patients.
• Pectoralis insertion anomaly: in 4 of 11 (36%), the pectoralis attached far from the sternum; in such cases the insertion is released during surgery so the implant fills toward the inner breast.
• Breast asymmetry: in 4 of 11, one (right) breast was smaller.
• Hypoplastic breasts: all 11 had underdeveloped breasts.

These five are structural features that do not read as a simple “sunken sternum,” and identifying them on preoperative physical examination — especially chest palpation — matters. The pectoralis insertion anomaly in particular, seen in about 36% (4/11), is included as a preoperative assessment item.

2. “Big implant = solution” is a common misunderstanding

Many who come with pectus excavatum want a large implant. It has to be seen the other way: trying to fill the sunken sternum with the implant only spreads it outward while the center stays as it was. It is easy to think, on appearance, that filling the depression with the implant will flatten it naturally — but in actual surgery it does not. Approaches that raise the risk: excessive medial dissection, with the pocket crossing the midline; and a pocket forced to bring the cleavage together, which can produce symmastia. Possible complications: symmastia (the two pockets merging at the midline), malposition, an unnatural intermammary contour, and long-term pocket instability. The core message: the key to pectus-excavatum augmentation is not “placing large” but “how far to safely build.”

3. The clinical core: right base width and pocket control

In pectus excavatum, the width is set first — a width matched to the chest wall must be fixed before volume is chosen within it. Three clinically important principles:

An appropriate diameter over an oversized implant

Implant selection follows the High Five system standard for all augmentation (Tebbetts & Adams, 2005),^[2] weighing five things together — breast base width, overall chest width, sternum contour (depth and width of the depression), the stretch and elasticity of the skin envelope, and soft-tissue thickness. Simply widening to hide the central depression can be risky.

Medial pocket control: making cleavage while keeping the border

Cleavage can be made, but crossing the midline leads to symmastia — so clinically, keeping the medial border matters more than making the cleavage. In pectus excavatum especially, the sternal depression can blur the midline border, so medial dissection is approached more conservatively than usual.

A fat-graft adjunct when needed for residual depression

Residual depression is sometimes not corrected by an implant alone; a small fat-graft adjunct can help smooth the contour. Moscona 2011 reported that in 2 of 11 patients an upper-breast depression the implant did not cover remained after surgery, where a small fat graft can be considered.

4. What Moscona 2011’s “wide implants” means

Moscona & Fodor described using “wide silicone implants.” The phrase alone is easily read as “pectus excavatum uses wide implants,” but reading the paper closely, the core is not implant size. What it actually emphasized:

• Minimize lateral dissection, guiding the implant to sit medially.
• Position medially with precision, naturally camouflaging the look of the sternal depression.
• In some cases (4 of 11), release the pectoralis sternal insertion so the implant fills toward the inner breast.
• Add a fat graft for residual depression (2 of 11), supplementing where the implant alone falls short.

In other words, the core was not a large implant but pocket design and chest-wall camouflage. This aligns with the current Korean aesthetic approach: not “wide implant = pectus solution,” but a pocket design and camouflage strategy matched to the patient’s chest-wall structure decides the result.

5. Three principles of a safe approach

What to watch most in pectus surgery is the pocket. On a sunken chest wall the implant slides medially easily, so how far the medial border is opened governs the result. The direction settles into three principles:

First, do not force-fill the depression

Correcting a chest-wall skeletal deformity with an implant alone is difficult. The goal is external camouflage, not correction of the skeleton itself — and patient and surgeon recognizing this together matters.

Second, do not force the cleavage together

Excessive medial dissection raises the risk of symmastia. Even in ordinary augmentation, conservative medial dissection is the key to a stable result; in pectus excavatum, the sternal depression can blur the midline border, so it is approached more conservatively.

Third, make the whole seat of the breast natural

The balance of width, projection, pocket, and soft tissue matters. Emphasizing one element alone — a large width, say — collapses the others. Setting this balance at the measurement and design stage is the decisive variable in satisfaction.

Summary

• Mild-to-moderate pectus excavatum can be approached with augmentation alone. In Moscona 2011’s 11 patients followed up to 4.5 years, the result was good with no major complications.
• It needs a different approach from ordinary augmentation. The five accompanying findings (sternal depression, chondrocostal junction depression, pectoralis insertion anomaly 4/11, asymmetry 4/11, hypoplasia 11/11) make preoperative assessment central.
• The key is pocket design, not a “big implant.” Appropriate base width, medial pocket control, symmastia prevention, and a fat-graft adjunct when needed go together.
• Moscona 2011 was a study of camouflage strategy. Rather than the phrase “wide implants,” the essence is minimizing lateral dissection, precise medial positioning, pectoralis release when needed, and a fat-graft adjunct.

References

1. Moscona RA, Fodor L. How to perform breast augmentation safely for a pectus excavatum patient. Aesthetic Plast Surg. 2011;35(2):198–202. doi:10.1007/s00266-010-9583-x. (11 patients; up to 4.5-year follow-up; no major complications.)
2. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process. Plast Reconstr Surg. 2005;116(7):2005–2016. doi:10.1097/01.prs.0000191163.19379.63.