Breast augmentation is one of the most common cosmetic procedures performed in the world. Over three-hundred thousand women in the US undergo this surgery every year. For over five decades now, there have been multiple generations of different types of breast implants and there have been multiple different techniques used for implant placement. Each new implant and different placement techniques have their respective fans on both the physician and patient side. All of these issues are open to debate. However, on the issue of breast implant size, I now think informed surgeons know that the data shows bigger is not better.

When I meet with patients in consultation regarding their desire for breast augmentation, they frequently come in to see me with a preconceived idea of what size they want to be. Often they mention a particular cup size, but occasionally they will mention an actual implant volume. I certainly welcome well-informed patients who have done their research. However, on querying many patients on these issues, I have discovered that much of their information regarding desired implant size comes from friends who have had the procedure, or the Internet. In reality, neither of these sources are particularly beneficial when it comes to selecting implant size.

When I first started my training in plastic surgery, in Texas, in 1994, many plastic surgeons allowed their patients to select their implant size. Little discussion was had over what would fit best, or the potential down-sides of implants that were too large for the patient’s frame. I came away from those experiences believing that everything is bigger in Texas! I was disenchanted with some of the results I saw, and even further disillusioned by the difficult revisionary surgeries that I saw some patients going through as a result of their over-endowment. I vowed at that time, that when I started my own practice, I would take a more conservative approach to breast implant size recommendations to my own patients.

At that time, there was not a lot of data on how larger implants effected patients long term. I based my decisions and philosophies on the fact that I felt more natural appearing results looked better. As I gained more experience with the procedure over time, and had long term patients in my own practice, I saw that on the rare occasion a patient would talk me into larger implants than I thought were perfect, they frequently re-appeared some years later with their implants out on the sides of the chest with wide cleavage, or worse with implants dropped below the fold underneath the breast.

After the “implant crisis” when silicone implants were removed from the market for a few years, plastic surgeons started to concentrate on techniques to decrease breast augmentation revision rates. As this issue was studied, it became known that implants larger than 350cc’s had dramatically higher revision rates than implants in lower size ranges. Problems with visible rippling, mal-position, and excessive tissue thinning were all more common in larger implant sizes. A “bio-dimensional” approach to implant size recommendations started to gain traction, meaning measuring the chest wall width, the thickness of existing breast tissue and the quality of the skin started to be taken into consideration, before recommending an implant size. With this approach, (that I always had embraced before it had a name) breast augmentation revision rates have dropped precipitously.

The width of the breast prior to surgery is one of the more important parameters to consider. As implants get bigger, they get wider and heavier. If a breast implant is placed that is wider than the natural breast, the implant will have a tendency to slide out to the side of the chest over time. This stretches the skin and widens the cleavage. Neither of which are desired and both of which frequently lead to patients seeking a revision. It can sometimes be difficult for patients to understand that bigger isn’t better until they have lived through this unfortunate loop. I would prefer to spend extra time with patients explaining the very real down-sides of implants that are too large, rather than set them up for revisionary surgery. It is true that I lose some patients to other surgeons that will put in whatever size the patients desire, but I have seen a few of these patients back in my practice for revisionary surgery down the road.

Before having breast augmentation, do your homework and select consultants who are board certified by the American Board of Plastic Surgery, who perform a large number of breast augmentations. Ask them how they determine implant size recommendations. If they say, “You can have whatever you like!” keep looking.

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