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Very frequently a few months after surgery
the patient wishes the implants were larger, and yet before surgery the same
patient was afraid they would be too big. The same patient may wish the implants
were smaller for some occasions, such as jogging and participating in athletics,
and would like them larger at other times, such as for evening wear or to fill
out a bathing suit. Let us recognize that cosmetic patients are the type of
persons who are generally displeased with their appearance, and though the
surgery may improve the appearance, it does not alter the personality type. They
still wish to be better, which is a healthy wholesome attitude so long as they
are not inclined to take excessive risks to achieve tiny, unnoticeable, vague
and ill-defined gains.
The most common question regarding size
patients ask is, "What size would I need to be to fill a C or D cup
bra?" Or the patient may simply say, "Make me just large enough to
fill a C cup with a little fullness." This request sounds simple and direct
enough, but not only will it require a different size implant for each person,
but it may also require a different size for each breast on the same patient.
The answer to the question of how many cubic
centimeters (ccís) of implant size are required depends upon how much breast
tissue the patient already has. This may be different for each breast, and the
two breasts may already be unequal in size, shape, position of areola and
presence/absence of inframammary folds. The patient also may genuinely and truly
be unaware of the minute differences in their breasts until they are pointed out
to her, even though she may realize one is a little smaller than the other.
Also, the different bras and manufacturers have different dimensions for a C or
The best answer to choosing the right size is
the sandwich baggy technique.
If the patient will go and purchase an
inexpensive bra with the cup size she desires to fill, then she can easily
determine how much additional volume will be needed to fill the cup of the bra
in cc's with a sandwich baggy filled with water.
A cc is a cubic centimeter and it is the same amount as a ml which is a milliliter or one thousandth of a liter. Most all kitchen measuring cups are now marked in cups and ounces as well as the metric system showing mls or milliliters.
The amount needed to completely fill a c cup of a bra might be about 10 ounces or 330 ccs. However if there is already about 130 ccs of breast tissue then only 200ccs is needed to fill that c bra cup.
If the patient takes some socks in her
handbag to the store with her, she can fill the bra with the socks while trying
it on to see that it is the one she wants to make her look good.
Then, when she gets home with the bra she has
selected, she fills a sandwich baggy with water until she achieves the size that
produces the most desirable appearance by placing the filled sandwich baggy in
Once she has determined what sandwich baggy
volume makes her look best, all she needs to do is measure the water in the
sandwich baggies by pouring it into a graduated kitchen measuring cup marked in
cc's or milliliters (mlís). We demonstrate this process and show the patient
how to do this on her first visit to the office by having her place sandwich
baggies filled with 250 to 350 cc's of water in her bra. She is allowed to do
this in front of a large mirror, in the privacy of an exam room with an
assistant to help her. In this way, she can understand the idea and see how she
will look with her top on and off using different volumes of water.
With this SANDWICH BAGGY TECHNIQUE, the
patient can determine as exactly as anyone what size will be best for her. It
should be pointed out to the patient that there is almost no detectable
difference in 10% more or less, and we ask our patients to grant us a variation
of at least that amount, depending on what looks best at the time of surgery.
The water-filled sandwich bag sits out in the
bra and does not fill all the areas that need to be filled to provide the
forward bra-cup filling projection and shape. In other words, the sandwich baggy
technique usually underestimates the volume required to produce the expected
result, and this is especially true if the implants are placed in the
sub-muscular position. As a general rule, for the above-muscle position we
recommend adding 10% to the estimated sandwich-baggy volume and 20% for the
Should there be problems with the implants in
the future - capsules, sagging, stretching of the breast skin due to pregnancy,
breast cancer, etc. - one may find that the problems with the implants are
smaller problems if the implants are smaller. Larger implants may cause some
pressure atrophy and thinning of muscle, subcutaneous fat and breast tissue, or
possibly even the ribs when the sub-muscular position is used.
Occasionally the patient will
choose size of implants that is too large, and need to be warned that if an attempt were made to
overstretch the skin, stretch marks and many other problems could develop. Also, the smaller the
implant, the fewer problems with capsule contraction may occur, because
relatively more breast tissue will be covering a smaller implant. Therefore,
with smaller implants, there will be less of a noticeable feeling of firmness,
as well as a reduced possibility of distortion with the same amount of capsule
The patient who appears to be choosing too
small a size should be informed of the nicer appearance larger breasts may have,
and the before and after pictures are helpful in explaining this. As soon a
surgeon has done 100 cases, they will have a nice collection of before and after photos
to show patients.
The most common error in all of the choices
made by patients is having chosen implants that were too small. Allowing the
patient to have as much choice and play as much of a role in choosing every part
of the operation leads to greater patient satisfaction and the reduced
possibility of regret or remorse from not having the most desirable result.
Showing the patient a book of before and
after photographs allows the doctor or his assistant to ask which ones the
patient most would like for herself. It also helps the patient understand what
she will obtain from the procedure to see someone who looks like she did before
surgery, and to see what they ended up looking like afterwards.
At this point it is wise to explain to the
patient that while there are some choices the patient may have, the exact shape
of the breasts, the areola, and the nipples cannot be chosen with any certainty
when surgery is limited to placement of breast implants. Implants control the
size or volume of the breasts but not the shape (except to a limited degree),
and implants cannot change the degree of breast sagging, drooping, symmetry in
position or shape, or size or shape of the areolae or nipples.
Asymmetry in volume can be adequately
corrected, and occasionally this (combined with a change in the position of the
inframammary fold on the smaller side) can do a lot to make the breasts look
more alike. Other asymmetries, such as an inverted nipple on one side, a large
areola on one side, a unilateral ptosis, etc., can be corrected by various
techniques, but not by breast implants alone.
Asking the patient to bring in pictures from topless magazines or other sources can be helpful on a preoperative visit. This can allow the surgeon and his staff to see the patient's wishes and expectations in regards to the look, size and shape of the chest she wants.
A very clearly worded disclaimer (such as our
surgery consent provides) stating that the patient will not look like any
certain photographs or drawings or other persons is needed.
All this discussion of size and the choosing of other alternatives are best done days or weeks before surgery to give the patient adequate time to study the options and think about what she wants to be. Otherwise on the morning of surgery if the patient and surgeon have not agreed upon what is best, the patient may bring in photos of what she desires and expects that the surgeon feels cannot or should not be done.
Further comments of the choice of the implant size follow below.
Implant size is the choice of the patient. The sandwich baggie technique that we demonstrate provides the best method of determining implant size that we have ever seen.
With the sandwich baggie technique you get an idea of the feel and weight as well as the size. Whatever size is chosen with the sandwich baggie technique we recommend that you add 10% more above the muscle or subfascial and 20% if below.
For example if you choose a 300cc sandwich baggie filled with water you should add 30cc. Because when the implant is inside you it will seem to disappear.
A very common complaint after surgery is that the person chose too small. A woman choosing breast implant surgery usually wants to be larger. And maybe the goal should be to have a beautiful chest. Necessary for beauty is a natural appearance and feel. Overly large implants lose that.
Happiness increases with larger implants up to a point. A person who chooses too small may be somewhat unhappy , but the person who has chosen an implant that is too large can be very unhappy, and much more unhappy than the person who is too small.
Our experience with women for many years and in conferences with other doctors is that women who are unhappy because they are too small are much less unhappy then women who have chosen an implant too large. Too big is worse than too small.
There are many good reasons that large breasts are more of a problem than small breasts. One is that with small breasts or small breast implants you could always go larger without any scars, but the reverse is not true.
An operation to make the breasts larger is straight forward and usually with no visible scars.
The reduction or breast lift operation to reduce the size of or to lift the breasts invariably leaves permanent scars that can be deforming and disfiguring and very unattractive.
Blowing the breasts up with implants so large that the skin becomes irreversibly stretched, and having gravity over the years pulling the breasts down because of the weight of the large implants, and lead to the need for the a breast lift or reduction operation that will leave permanent scarring. At that time it will become clear that a happier choice would be to have less large implants that can still look good for a lifetime without drooping and sagging.
We will be happy to show you in textbooks and in pictures in the office the scars from the reduction and breast lift operation. It can be seen in all the photographs of the results of these operations for lifting the sagging breasts that most persons feel that patients with this operation do not look good with their clothes off. Though the shape may be good, they don't look good because of the scarring. Therefore, for this reason alone it is unwise to choose implants that are too large.
There are several other reasons it is not good to choose very large implants. The goal is not only to look good but also to feel good and natural.. If very large implants out of proportion to the amount of breast tissue present are chosen, the skin will be stretched and thin. The implants will therefore be more palpable and visible through the thin skin.
Several other problems such as hardness and rippling are also proportional to the size of the implants.
If the implants are small, any hardness and rippling is a small hidden problem. If the implants are larger, rippling, hardness and palpability of implants are much more obvious.
The majority of patients have one or more of these problems with their implants. Therefore the persons who have smaller implants are much happier over the long term
The bigger the implants the bigger are most problems that occur with them.
Another big factor with drooping and skin stretching is that stretch marks can occur.
Therefore choose the smallest size you can live with for the most beautiful natural results.
For the doctor it is just as easy at the time of surgery to use large implants 600cc, 800cc, 1200cc as it is to use the most moderate size 300cc or 400cc that most people choose. Also the implant cost is the same for small to very large implants.
In other words the surgeon has nothing to gain by using smaller implants.
But we must warn you of all these problems. Because unhappiness with large implants can be extreme.
Advantages of large implants are fairly obvious and could include:
1. Large voluptuous breasts
2. Fill out clothes and bras easily
3. attractive as much as larger breasts could be
4. would make the hips and waist appear smaller
All of the above advantages are already known to most young women, and are part of the reasons for wanting breast implants.
Disadvantages of large implants are not so well known and may include:
1. All of the common problems that frequently occur with implants are larger problems, i.e. more serious and troublesome with larger implants such as:
1. hardness due to capsule contracture
2. visible distortion due to capsule contracture
3. visible detectability of the implants i.e. looking at them you can tell they are implants
4. rippling appearance and feel
5. palpability i.e. anyone feeling the breasts can tell they are implants because they feel like plastic bags of water
9. interference with breast feeding
10. more chance of the stuck on or coffee cup on the chest appearance
2. also drooping and sagging of the breasts are more likely with larger implants
3. a breast lift or reduction may be needed and these operations usually leave very noticeable, disfiguring, unattractive scars.
4. stretch marks are more common
5. larger implants can interfere with sports such as horse back riding, jogging, tennis, golf, badminton, racquet ball, archery, bowling, swimming, diving, ballet, modern dancing, figure skating, and many other sports and activities
6. larger implants may interfere with many daily activities as carrying groceries or packages, caring for children, sleeping, turning over in bed, dressing and undressing
7. larger implants may make a person appear more mature or older especially when gravity has pulled them down
8. pregnancy with larger implants often further magnifies and makes worse all of the above problems
9. If there is a desire to make the large implants smaller after they have been in place for months or years, the skin having been stretched by the large implants usually will not contract and a breast lift or reduction operation is needed to use smaller implants. The breast reduction operation for this leaves the anchor scar around the nipples and down the front of the breast, and these scars are often quite unattractive and disfiguring.
10. Choosing too large is more irreversible than too small which can be easily corrected.
And so in conclusion, while at a distance or on film the bigger the better for breast implants may be true, but most women in real life want to be as natural as possible and not have an abnormal implant look or feel. There is no question that overly large implants are much more likely to be unnatural in appearance and feel and have more problems as explained above.
Even though breasts are associated with mothering, no studies are known to show that small breasts are related to personality characteristics such as affection, sympathy, kindness or generosity as compared to women with larger breasts. Nor are women with small breasts necessarily found to be more intelligent, but they do seem to sometimes be better in certain sports.
The following is a consent that can be used in regards to the choice of implant size.
As a woman who is choosing to have breast implant surgery, I understand that the choice of the size of the implants if up to me and mine to make. It is my responsibility what size I choose. And my happiness or displeasure with the size is entirely my responsibility. And this information about the consequences of the choice of size is to help me choose what is right for myself for now and in the future. And this information is not intended to sway me or convince me that one size is much better than another.
And therefore it is with understanding of all this information and of the pros and cons of implant size I choose for myself the size range of ccís or mlís.
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1984-2014 American Society of Cosmetic Breast Surgery Last modified: March 28, 2014