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In search of Goldilocks' breasts

Size matters. I once had a body builder come in with an infected biceps implant. I don’t insert these as the complication rate is high and, personally, I just don’t like this type of surgery. I asked the fellow, whose biceps were already huge, why he had implants put in at all. His answer was telling. He said, “you know how it is, Doc, when you have 28 inch biceps, you want 29 inch biceps”.

Imagine for a second if Goldilocks, when she was older, had sought breast implants. After the first operation, she would have exclaimed, “these implants are too big!”. After a revision, she would have observed, “These implants are too small!”. After her exasperated plastic surgeon revised her yet a second time, hopefully she declared, “these implants are just right!”.

The holy grail of breast implant surgery is the augmented breast that looks and feels natural and is the perfect size for the individual. Focusing on the latter issue, what is the perfect size breast? The answer to this question is as varied as are the women who seek breast augmentation. What is perfect to one is too large for another and too small for yet a third individual. Figuring out what size implant to choose for a patient is a large part of the “art” of this procedure.

I spend more time than most plastic surgeons in my initial consultation for breast augmentation, at least 45 minutes, sometimes more. I want patients to be very well informed when a making a decision for this surgery. A significant part of that time is spent on size. Many young women request a specific bra size they wish to be after surgery. Most are unaware that there is no uniform standard for bra cup size. Unlike the 12 inch ruler, which uses the standard for an inch accepted internationally and by our own American National Standards Institute, there is no comparable standard for cup size in bras. Each manufacturer makes bras according to their own, in house standards. That is why you can purchase a bra from one store in a B cup and from another in a C cup, and both fit you the same. VictoriaÂ’s Secret is notorious for making their bras smaller so that women wearing a B cup from, say a major department store, will wear a C, or even in some cases a D cup from VictoriaÂ’s Secret. I suppose this probably makes them feel better about their breast size.

As part of my examination, I take extensive measurements of the breasts but this is just so I can see how these change after surgery. There is no formula that I can plug these numbers into in advance of surgery to tell me what implant size to choose for that patient. There are computer programs that will take a photograph of a patientÂ’s breasts and allow the surgeon to manipulate or “morph” those breasts according to mathematical algorithms to show what the breasts will look like with different size implants. The problem with these is that they donÂ’t exactly duplicate what happens in real life. Even if they did, it does not guarantee that the patient will be happy with those breasts. Seeing a result on a computer screen and then living with those implants are two very different things. Some surgeons have patients stuff different size implants in their bra to see what they like. The fallacy here is that this will not tell them how those implants will look and feel inside their breasts. In short, there is no formula, computer program, or other manipulation in advance of surgery that can guarantee that a patient will be happy her implant size.  

The first thing I do to help me determine the best size implant is to listen to my patients. This is perhaps the most important step of all. Most patients will tell me what they want. Besides a specific cup size, they may wish to be well proportioned, to look normal, to regain lost fullness, to fit into clothing better, avoid being “showy”, and so on. A few ask to be “showy” or even want to look clearly enlarged. The interview gives me an idea of what they are looking for.

The examination is helpful in assessing the breasts for tightness or looseness of the skin and breast tissue, the dimensions of the chest, and more, which determine some of the limits of what the breasts will accept without creating problems.

I inform all patients about my practice of sizing patients during the surgery, by inserting temporary implants called “sizers”, into the breasts during surgery. I can inflate these to any size I wish to see and feel what they do to the breasts. Based on years of experience, I can anticipate how those implants will settle. I have 2 nurses and an anesthetist in the room with me and they add their opinions as well. We never failed to reach a consensus on the best size. With a couple of exceptions, I have sized every patient this way for 23 years. The exceptions were patients who selected their own implant size. Every one of these has been unhappy with the size they chose, feeling they chose too small. With my method of selecting size, I have had happy patients in well over 95% of my augmentations. No surgeon I have ever heard of achieves 100%.

Despite all of my efforts to give patients what they want, the few that feel they are too small (only 2 patients in 23 years have felt they were too big) often do not seem to be able grasp the imperfection inherent in sizing patients. One unhappy patient repeatedly asked me why I didnÂ’t give her the size she wanted the first time and could not accept any answer I could give her. One patient told me that the implants she received did not produce any change in her bra cup size, despite the fact that these same implants typically produce a increase of one to two cup sizes.

If a patient is unhappy with her implant size, she does have options. I suggest living with the implants for a while, say a year. Some women just need time to get used to their new size and most end up pleased and do not seek revision surgery. For those that do choose to replace their implants, I charge only my out-of-pocket expenses and the price of a new pair of implants. I do not charge for my time in providing this additional surgery. Of course, I cannot guarantee they will get the perfect size they wish the second time either. So far that hasnÂ’t happened, Goldilocks case notwithstanding.

Patients undergoing breast augmentation need to understand that no one can guarantee that they will get the exact size they were seeking. This degree of perfection just simply doesnÂ’t exist. 


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