A flat chest can be genetic, hormonal, developmental, or related to life changes such as weight shifts, pregnancy, or menopause. Michael Baumholtz, MD, approaches this concern the same way he approaches every operation in his practice: careful listening, clear education, realistic planning, and meticulous technique. His focus is proportion, safety, and a plan that fits a person’s daily life.
This guide explains why some people have a flatter chest and outlines the options he commonly discusses in consultation. It is written for anyone considering breast augmentation or shape correction, including individuals with developmental differences such as tuberous breasts, pectus, or Poland syndrome. It is not a substitute for an in‑person consultation.
Why Some People Develop a Flatter Chest
Breast size reflects a mix of genetics, hormones, and the underlying chest wall. During puberty, low levels of estrogen and progesterone can limit glandular growth, and disorders of the thyroid or pituitary can contribute as well. Lifestyle and medical stressors - such as restrictive dieting, intense endurance training, major illness, or chronic stress - may blunt development in adolescence. In adulthood, volume often decreases with weight loss, after breastfeeding, and during menopause as natural tissue involutes; these are normal biological shifts that can still feel out of step with how someone expects clothing to fit. The chest wall also matters. Pectus carinatum and pectus excavatum change the position of the ribs and sternum, so breasts can look flatter even when tissue is present. Poland syndrome may leave one side with underdeveloped tissue or a difference in the pectoral muscle. Tuberous (tubular) breasts are different again: the base is constricted, the fold may sit high, the areola can appear wide, and projection is limited. Addressing that pattern requires releasing the tight base and reshaping the lower pole; size change alone rarely looks right. None of these patterns is rare or something to be embarrassed about. They are simply varied starting points, and planning should match the anatomy rather than a trend.
How Dr. Baumholtz Plans - The Framework
A successful plan starts with careful measurement and a clear discussion of goals. Dr. Baumholtz begins by establishing the breast base width, because that dimension anchors implant selection and determines the safe range of projection. He then evaluates skin quality and elasticity; thicker, more elastic skin typically accepts volume and settles into a stable shape more predictably, while thin or stretched skin may benefit from internal support. Nipple position and the footprint of each breast on the chest wall are mapped in detail, including the location and definition of the inframammary fold. The chest wall is assessed for pectus and rib asymmetries that could influence how an implant appears even when breast tissue is symmetric. To align expectations, he reviews reference photos and uses in‑office sizing to approximate the desired look, while also recording the features the patient wishes to avoid. He does not rely on cup letters - labels vary widely - and he does not use 3D body imaging systems for this planning; precise measurements and in‑office sizing remain his standard.
Option 1: Breast Augmentation With Implants
For most people seeking a noticeable and predictable size increase, implants are the most reliable tool. Both silicone gel and saline devices are used in the practice. The choice depends on age, anatomy, lifestyle, and personal preference.
✓ Silicone vs. Saline - How He Discusses It
Both silicone gel and saline implants are used in the practice. Silicone gel devices generally feel closer to natural tissue and ripple less in thinner patients because they are pre‑filled and cohesive. Saline implants are filled after placement, which allows a slightly smaller incision and fine‑tuning of volume during surgery. In the United States, cosmetic augmentation typically offers saline beginning at age 18 and silicone at age 22; for congenital differences or reconstruction, silicone may be considered younger than 22 after case‑by‑case evaluation.
✓ Pocket Placement - Where the Implant Sits
Dr. Baumholtz frequently uses a dual‑plane submuscular pocket, with the upper part of the implant beneath the pectoralis muscle and the lower part beneath the breast tissue. This approach tends to soften the upper transition, improve the overall slope, and add coverage over the device - advantages that are particularly helpful in thinner patients. A subglandular pocket on top of the muscle may be appropriate for individuals with adequate soft‑tissue coverage who prefer a quicker return to certain upper‑body activities. The choice is individualized after discussing exercise habits, work requirements, and tissue thickness.
✓ Incision Choice - Why He Favors the Inframammary Fold
The inframammary fold (IMF) incision is his standard for most primary augmentations. It provides direct access for precise pocket creation, avoids traversing breast ducts when possible, hides in the natural crease as it heals, and can be reused for future revision. He incorporates no‑touch insertion with a sterile funnel, Betadine prep, and meticulous pocket control to limit bacterial exposure and support clean, durable fold definition.
✓ Device Selection - Conservative and Proportion‑Driven
Device selection is conservative and proportion‑driven. Dr. Baumholtz typically uses smooth, round implants from manufacturers he trusts, including Allergan and Motiva. Round devices assume a gentle teardrop profile when upright without the rotation concerns seen with true anatomic shapes. He does not use macro‑textured implants. When tissues are thin, or when a larger device is necessary to reach the agreed‑upon goal, he may place an absorbable mesh as internal support. This soft, temporary lattice helps maintain fold position and early shape while the body adapts.
✓ What Implants Can and Cannot Do
Implants add volume and projection, and they can help restore balance across the torso. They do not correct significant nipple malposition or a stretched lower pole on their own; those issues generally require a lift. They also do not fix major chest wall asymmetry; pocket design and, when helpful, fat transfer are used to address that. Understanding these boundaries makes it easier to match the operation to the goal and to select techniques that hold up over time.
Option 2: Fat Transfer - Subtle Volume and Smoother Borders
Fat grafting uses a person’s own fat to add soft volume and refine shape. Dr. Baumholtz applies this tool selectively to soften the upper inner breast, reduce visible edges, and correct small side‑to‑side differences. The process begins with a gentle liposuction harvest - often from the abdomen, flanks, or thighs - followed by purification of the aspirate and layered placement through small incisions. A portion of the transferred fat will not survive; the percentage varies among individuals and even between sides. Because of this, fat transfer is best suited to modest shaping rather than large jumps in size. Swelling diminishes over weeks, and the final take of fat is judged after several months.
Developmental and Complex Situations
Tuberous Breasts - Why Simple Augmentation Isn’t Enough
When the base of the breast is constricted and the fold sits high, a straightforward augmentation will not look right. Correction involves releasing the tight base to allow the lower pole to expand, lowering and redefining the fold so the breast has a normal footprint, adjusting the areolar diameter to match the new shape, and adding an implant to provide projection and proportion that natural tissue cannot achieve alone. Fat may be layered to soften borders and blend transitions. Because severity often differs between sides, each breast is planned independently.
Chest Wall Differences and Poland Syndrome
Pectus and Poland syndrome change the underlying framework, which in turn influences how an implant sits. Dr. Baumholtz tailors pocket design to offset rib or muscle differences, considers staged soft‑tissue expansion when skin is unusually tight, and uses fat layering to camouflage transitions along the sternum or lateral chest when helpful. The goal is a chest that looks proportional in motion and clothing, achieved with techniques that the tissues can reasonably support.
Safety Principles That Guide Every Case
Safety drives both timeline and technique. Standard steps include antiseptic prep with Betadine, pocket irrigation, glove changes, and no‑touch device insertion using a sterile funnel. He does not use macro‑textured implants. Device‑related conditions - such as Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA‑ALCL) - are reviewed in plain language, along with the symptoms that should prompt evaluation. Conversations about breast implant illness (BII) are handled with the same care. He acknowledges that some patients report systemic symptoms; together they review the medical history and weigh the risks and benefits of any proposed operation. If device removal is the right choice for a given individual, the procedure is planned to prioritize safety and set expectations for the likely changes in shape. Long‑term follow‑up is part of responsible care because implants are medical devices and may need service in the future.
Managing Expectations and Choosing Size
Cup letters are not a dependable sizing system because brands vary widely. Dr. Baumholtz relies on base‑width measurements and proportional planning. Projection is chosen to match the measured width, and he explains that pushing beyond what tissues can safely support increases the likelihood of fold malposition or other avoidable problems. He also considers the broader frame - shoulders, waist, and hips - so the result looks like it belongs on the person’s body. When someone wants a large change that tissues cannot safely support in a single operation, he may recommend staging. This protects the skin and fold and reduces the need for aggressive releases. Reference photos help establish direction, and documenting features to avoid is often as helpful as naming desired features.
When a Lift Is Needed
An implant changes volume; a lift changes position. If the nipple sits well below the inframammary fold or the skin envelope is stretched, mastopexy may be needed to center the nipple on the mound and tighten the envelope. When appropriate, Dr. Baumholtz performs augmentation and lift in a single operation, balancing skin tightening with preservation of the nipple‑areola blood supply. Scar patterns - periareolar, vertical, or Wise‑pattern - are chosen according to the amount of reshaping required, and he explains the trade‑off between lift and scar burden. In selected cases, especially with thin tissues or larger devices, absorbable mesh is used to support the lower pole during early healing. Internal suturing helps define and protect the fold. The goal is a durable breast with a gentle slope and reliable fold control.
Recovery - What It Typically Feels Like
Recovery varies from person to person, but many describe a similar course. The first forty‑eight hours usually bring tightness and pressure across the chest, with prescription medication used as needed. Over the next several days most people transition to over‑the‑counter options. A soft, supportive bra is worn early to protect the fold and maintain shape. Light walking begins day one to promote circulation, and many return to desk work in about a week depending on the procedure and job demands. Lifting and upper‑body workouts pause for four to six weeks. Swelling gradually declines over several weeks, while implants settle as the muscle relaxes and the pocket matures; the final shape evolves over a few months. Sensation can fluctuate and typically improves as nerves recover. Incisions are kept clean and dry, with sun exposure avoided until cleared. Hot weather does not prevent safe healing; hydration, breathable garments, and dry incisions are the priorities.
Long‑Term Care and Follow‑Up
Access is part of the care plan. Dr. Baumholtz typically sees patients the day after surgery and schedules a series of routine checks during the first months, with extra visits arranged promptly if concerns arise. Over the long term he recommends self‑checks and age‑appropriate imaging. For silicone devices, he offers in‑office ultrasound screening and orders MRI when findings are unclear or when symptoms arise. Because implants are durable but not guaranteed for a lifetime, he discusses options if a device needs service in the future and plans the timing around health, anatomy, and personal goals.
Who Is a Good Candidate
Healthy, non‑smoking adults with stable weight and clear goals tend to do well with breast augmentation and related procedures. Individuals with complex anatomy - including chest wall differences or a history of prior surgeries - benefit from a surgeon who is comfortable with revision work; that is a regular part of Dr. Baumholtz’s practice. Surgery may be deferred during active weight change, soon before a planned pregnancy, or when medical conditions are not well controlled. Final candidacy is always confirmed after an in‑person assessment, a review of medical history and medications, and imaging when indicated.
What to Expect at Your Consultation
Expect a straightforward conversation about goals, concerns, and lifestyle. Photographs are taken for analysis and planning, and detailed measurements are recorded, including base width, skin quality, and nipple position. The discussion of silicone and saline is matched to age and anatomy, and incision choices are reviewed, including the reasons the fold is favored for most augmentations. An in‑office sizing session and reference photos help align expectations without relying on cup labels. The visit concludes with a written plan and a recovery roadmap that respects work, home responsibilities, and exercise routines.
FAQs About Flat Chest
I’m in my 50s and very active. Can limited development from my teens still be addressed?
Often, yes. Healthy individuals in their 50s and 60s can achieve proportional size with implants or a lift with implant after appropriate screening. Planning is built around activity level and tissue quality so the result feels appropriate for the body and daily life.
I have a narrow chest and visible ribs. Will implants look obvious?
For thinner patients, a dual plane pocket with a properly sized smooth silicone implant often softens the upper transition and helps conceal edges. When tissue is thin or a larger device is chosen, an absorbable mesh may be added for early support to protect the fold.
My breasts are small and tube shaped with wide areolas. Is that the same as a flat chest - and can this be corrected in one surgery?
That pattern suggests a tuberous breast. Correction usually includes releasing the tight base, lowering the fold, resizing the areola, and adding an implant for projection. Fat may be layered to smooth borders. Many patients can be treated in a single operation, but each side is planned independently because severity often differs.
If I choose silicone, how are implants monitored over time without lots of testing?
In this practice, in office ultrasound is offered to screen silicone shells, and MRI is ordered when findings are unclear or when symptoms arise. Contact the office promptly for sudden swelling, shape change, or new firmness so he can evaluate.
I prefer no foreign material. Could fat transfer alone give the size I want for fitted tops?
Fat transfer is well suited for subtle enhancement and shaping. Because a portion of the grafted fat will not survive, large size increases are not predictable with fat alone. Dr. Baumholtz frequently uses fat to refine results or correct small asymmetries rather than as the only tool for a major change.
Does hot weather change recovery instructions after augmentation?
Heat does not prevent safe healing. Hydration, breathable support garments, keeping incisions dry, and avoiding sun on early scars are the key points. Follow ups are scheduled in the office, with additional check ins if needed.
I’m under 22 and thinking about surgery during college. Are silicone implants an option for me?
In the U.S., cosmetic augmentation typically offers saline at 18 and silicone at 22. For congenital differences, silicone may be considered case by case. The safest answer comes from an in person consultation to review anatomy, goals, and medical history.
How long do implants last?
There is no single expiration date. Some people will never need revision, while others will. The device’s condition, the tissue response over time, and any change in personal goals inform the timeline. Long term follow up helps catch changes early and plan thoughtfully if service is needed.
What are the main risks I should know about?
All operations carry risk. For augmentation these include bleeding, infection, need for revision, asymmetry, capsular contracture, implant malposition, sensation changes, and issues that may require imaging or further surgery. Rare risks such as BIA ALCL are discussed in consultation. The pre operative visit includes a review of medications and steps to reduce risk.
Will I be able to breastfeed after augmentation?
Many people do, but it cannot be guaranteed. The inframammary fold incision is favored in part because it avoids traversing ducts when possible. If future breastfeeding is a priority, that preference is factored into incision and pocket choices.
What if I decide later that implants are not for me?
Device removal is an option. If removal is chosen, a plan is made for the likely change in shape and skin behavior. In select cases, a lift or limited fat transfer can help with contour after removal, depending on tissue quality and personal goals.
How do you decide between above or below the muscle?
The decision is based on tissue thickness, activity level, and the amount of coverage needed over the device. Below the muscle (often dual plane) provides more coverage and a softer upper slope for many thin patients. Above the muscle can be considered with adequate tissue, specific athletic goals, or revision scenarios where submuscular placement is not ideal.
Do you use textured implants or shaped implants?
No macro textured devices are used in this practice. Smooth, round implants are preferred; when upright they take on a natural teardrop like appearance without the rotation concerns of anatomic shapes.
What about the term “en bloc” I see online?
The phrase is often used incorrectly. When a capsulectomy is indicated, the technique is chosen based on safety and anatomy. The priority is removing what needs to be removed while preserving healthy tissue and blood supply, not chasing a label.
How do you keep surgery sterile?
Standard steps include antiseptic prep with Betadine, fresh draping, pocket irrigation, glove changes, and no touch device insertion with a Keller Funnel. These measures are routine parts of his workflow.
What is recovery like after a lift with implants compared to implants alone?
Both involve tightness and fatigue in the first few days. A lift adds incisions and skin tightening, so the initial soreness and incision care are more involved. The longer term activity timeline is similar: lower body activity early, upper body work paused for several weeks, and gradual return as cleared.
Can exercise change how implants look over time?
Certain heavy pectoral exercises can influence how a submuscular implant behaves during contraction. Pocket choice is adjusted if someone’s routine makes animation a significant concern.
Will insurance cover any part of this?
This practice does not participate with insurance for cosmetic augmentation. If a reconstructive indication exists, that is discussed separately along with documentation and imaging as needed.
Medical References
- Prevalence and incidence of chest wall deformities in children below 18 years old - https://www.archivesofmedicalscience.com/Prevalence-and-incidence-of-chest-wall-deformities-in-children-below-18-years-old,188876,0,2.html
- Overview of chest wall deformities. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC10995686/
- CONGENITAL CHEST WALL DEFORMITIES. Journal of Thoracic Spine Surgery. https://www.jtss.org/pdf/f942abf9-a73b-4057-b48b-c3a4b7d0c2a5/articles/28079/jtss-28-195-En.pdf
- Chest Wall Deformities. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK553073/
- Chest Wall Abnormalities and their Clinical Significance in Pediatrics. ScienceDirect. https://www.sciencedirect.com/science/article/abs/pii/S1526054213001565
- Diagnosis in chest wall deformities. Journal of Visualized Surgery. https://jovs.amegroups.org/article/view/10655/html
- Chest Wall Deformities in Adults With Fibrotic Interstitial Lung Disease. ScienceDirect. https://www.sciencedirect.com/science/article/pii/S2949789224000722
Putting It All Together - The Practical Takeaway
A flat chest can reflect limited glandular volume, chest wall differences, or both. The most effective plan addresses the specific reason rather than following a generic template. Planning is measurement‑driven; base width and tissue quality define the safe range for projection and device size. Implants remain the most predictable way to create a noticeable size change, and choices about pocket, incision, and device are individualized and explained in clear terms. Fat transfer is a valuable tool for modest shaping and for smoothing edges but is not a reliable path to large increases in volume. Developmental patterns such as tuberous breasts require base release and fold work before volume is added. Safety is a process that includes sterile technique, careful device selection, discussion of rare risks, and a long‑term follow‑up plan. Throughout, the aim is proportion that suits the person’s frame and lifestyle.
Next Steps
If you would like to talk through options, the practice team can schedule a time to meet with Dr. Baumholtz. Expect a straightforward conversation, measurements, a review of reference photos, and a plan that respects your goals and day‑to‑day life.
Contact: 210‑660‑5579
Email: info@bplasticsurgery.com
