I am getting silicone breast implants on Friday and am really scared of going too big. I am currently a "B"; I want to be a "C". I have chosen 350cc in hopes they will look like the 300-325 implant I tried at my doctor's office.
Do You Lose 50 Cc's with Behind the Muscle Silicone Implant Placement?
Doctor Answers 52
Breast size with implants over vs. under the muscle
There are many variables to consider when selecting the size of implant: The height and frame of a woman, how much breast tissue she has to start with, whether or not she has had children.
Cup size is also not consistent with bra manufacturers. A "B cup" to one company mught be a "D cup" to another. The best way to determine the size of the implant that is ideal for you is to have great communication with your plastic surgeon, usung your plastic surgeon's before and after images as a tool to help you communicate the size you are hoping to acheive.
In consultations I listen carefully to each patient to ensure that I clearly understand their goals for breast augmentation surgery. Based on that discussion, and on the physical examination, I go into surgery knowing what the ideal volume should be within two or three breast implant sizes. However, the patient and I do not decide on one particular size prior to surgery. There is absolutely no way, in my opinion, to know exactly what size implant is the ideal size for a particular patient in advance of creating the implant pockets in the operating room. For that reason I keep a wide range of implant sizes on hand in the surgery center.
If natural is the goal, then the way to get the size right is to 'try out' different implant volumes in the operating room. Once the implant pockets have been created, I place a 'sizer' in one implant pocket and have the upper half of the O.R. table raised so that the patient is in an upright 'sitting' position (chest fully upright). The sizer is then inflated gradually to the point that the breasts appear full, but not unnaturally so. In this manner, the exact volume that produces a full but natural breast profile is determined.
For any patient there is obviously a range of implant volumes that would be considered natural. While one patient may seek an augmentation that is 'the small side of natural', another may be interested in something that is more on 'the large side of natural'. By using breast implant sizers to determine exactly what breast profile a given implant volume produces in the O.R., I am able to provide patients with the closest possible approximation of their preoperative goals.
Just as important, if not more important than size is the position of the implants. If a woman is seeking a natural looking result, breast that are to far apart, too close together, or too high the chest will look like obvious breast implants.
Under the muscle implants should be larger than the sizers
One of the most uncertain things for women undergoing brest augmentation is to know what they will look like with a certain volume implants. And, as a surgeon, it can be difficult to understand what a women wants when she say she wants to be a full C cup of a small D cup.
The use of sizers during the pre-operative consulations has made this very much more straight forward. We will put our patients in a bra and then place different size implants in the bra to both let the patient know what they will look like with a certain size implants, and to let us know what the patient wants to look like. We will frequently do this several times with different tops.
But that's not the end of the story. There is not an exact one to one relationship between the sizer a woman wants and the implants we will use at the time of surgery. Gerneally speaking I will use an implant 50 cc larger than the sizer that is chosen if the implant is going under the muscle. If a very large implant is being used we may go up even a bit more in the size (60 cc's or so).
This has worked quite well for us. While there are always people who wish they were a little larger or a little smaller, this has really helped make the implant size selection more accurate.
Significance of implant size
The difference between 325 and 350cc. is less than10%. However, in general, size of implant is determined less by cc's and more by dimensions. Patients have a hard time understanding this and often get fixated on the cc's. The volume is the result of dimensional analysis, not vice versa. In fact, the volume tells nothing about the implants since a 350cc implant can have different dimensions (i.e. base diameter and projection) and thus produce different-looking breasts. The best way to choose size is to look at the base diameter of the natural breast and see what implants will give you the most natural look. This is usually the flattest or least projecting implant with the base width about the same as the breast so that the implant will be predominantly covered by the natural breast. You and your surgeon can then determine if this will give you the look you want (i.e. shape, cleavage, width, etc.). To up size, you can increase width or increase projection, or both, until you get outside your target look. There will usually be a few implants that will give you close to what you desire. I then ask a patient if she would be more unhappy being too large or being too small and vary my implant choice depending on her answer.
I have found that, in general, patients who are a little too small, wished they could go bigger but are less unhappy than women who are too big. The former still look good and more natural and can upsize with specific bras while the latter canot hide their excess size. Usually, in the long run, the smaller the implant, the less complications and side effects but speak frankly and specifically with your surgeon.
Going under the muscle does blunt the effects of the implants compared to on top of the muscle for the same implant but it is the relative, not absolute, size and dimensions of the implant that will determine how that implant will act differently in the two different locations.
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Implant larger than sizer
Essentially the question is that of: How do I choose the correct implant to get the look I am wanting? This is the most important question when it comes to breast augmentation. In order to better address this question, we need to establish 2 main points:
First: Implants do not come in "cup" sizes. They either come prefilled (in case of silicone gel implants) with certain volume or unfilled (in case of saline implants) with a range of fill capacity. In either case, the fluid volume is measured in terms of cc's (very much like a can of soda has 355 cc's or ml of fluid). This is important as many patients request for a certain "cup" size. For example, "I am currently a B cup but would like to be full C cup." So what implant should be used to achieve this? Before we answer this question, let us consider another important fact: most women are fully aware of the fact that bra cup sizes vary by the manufacturer, so with one manufacturer, one may fit into a B bra but may require a C bra with a different company make. In other words, there is variability even within "cup" sizes which makes using "cup" size as a measurement even more frought with potential errors.
Second: For most women, they are more interested in achieving a certain "look" rather than a certain "cup" size which I applaud. After all, as long as the new size "looks" good to you - do you really care whether you require a certain cup sized bra? I think most women would agree with this statement. With this in mind, the real conversion that needs to be take place is: once you've identified the "look" you desire, how do you and your surgeon go about picking the right implant to achieve that "look?"
There are many different ways to get a glimpse of the "look" that you are after. Many offices use gel sizers, others use rice bags, etc. They will all work. So once you've decided on a look that you are seeking, we need to choose the implant to give you that look. Now, because the sizer or the rice bag was placed ON TOP OF YOUR BREASTS, as opposed to under the muscle, I think it makes sense to think a LARGER implant than the sizer is needed to achieve the comparable look - after all, the implant needs to expand the muscle and at times, it needs to "fill out" the extra skin envelope of the breast (as is true for most women after pregnancies) before it starts to expand the breast. So the real question is: what is the conversion factor? If you liked the look of a 300cc gel sizer, then depending on how much extra skin you have, I personally add at least 30cc's to saline implants, and 50 cc's to silicone gel implants, thereby filling saline implants to a total volume of 330-340cc or choosing silicone gel implants of 350cc. At times, if you had chosen a sizer of 400cc, then I would fill saline implants up to 450cc or choose 475cc silicone gel implants - meaning the larger the desired look, greater the conversion factor. By the above discussion, you have already noted that silicone gel implants "fit" smaller than saline counterparts and give lesser projection.
I have been very pleased with the above conversion method - more importantly, my patients have been pleased with their outcomes, as they got the look they were seeking. It's not perfect, but comes pretty close.
Hopefully this helps.
Volume does not change, but Visual size does.
The hardest part about performing breast enlargement surgery is getting on the same page as my patients with regard to breast size. Often, there are conflicting points of view that confuse an already nervous patient. There are friends telling the patient that they should not do it at all. There are those at the other extreme telling them to go as big as possible. And in the middle are friends telling them that they should go bigger than the doctor suggests or more specifically the dreaded " I have 350's, that is what you should get!"
Lets start by saying that breast enhancement is not for everyone. So those friends that tell you not to have breast enlargement are obviously in that camp.
For those that think you go as large as possible are looking at the media driven ideals that bigger is better. However, consider the serious risks to your health when going very large. At the least, you set yourself up for early sagging breasts and neck or back pain. From an aesthetic point of view, you are no longer considered to be natural. Very large implants scream "Look at me!". If that is what you want - great- but don't do that because your friends or a passing boyfriend suggest it.
Finally, for those in the middle, wavering between sizes - go and have a long discussion with your doctor. Make sure that he or she is on the same page as you. All implant discussions should start with evaluation of your chest wall width. This will create a limit for the width of the implants. Then decide on the type of projection you desire. I tell my patients that projection comes in three sizes 1)natural and full 20Natural but very sexy and 3) In your face. This translates for the physician into low, medium or high profile implants, respectively. The dimensional concept negates your frineds request for you to get the same ones as her, because her chest width and preexisting volume may be much different than your own.
Once you know the volume, go perform a rice test at home. Pour rice into a measuring cup to the amount decided. Then pour it into one leg of a pair of panty hose, tie it off and insert in your bra. This should mimic the volume of the implant but appear about 10% larger than the actual volume. Hence, if you like 330cc in rice, then you would like 360cc when placed under the skin, behind the muscle.
No such thing as too big?
Although there is such an entity as "too big", this is rarely the case in breast augmentation surgery. In fact, the saying "I should have gone bigger" is also becoming a dinosaur. The reasons:
1. American Board of Plastic Surgery plastic surgeons take painstaking efforts to try to size the implants to fit your body characteristics and your wishes. Often we have several preoperative consultations to very accurately determine what implant size is right for you.
2. Implant availability. Breast implant manufacturers have greatly increased the number of implant size and shape (projection) choices so that we may much more accurately match your implants to your needs.
Placement of the implant behind the muscle will somewhat decrease its projection, but volume is volume and once the muscle relaxes after the surgery the compression effect of the muscle will be less visible. However, your dilemma about 350cc vs 300-325cc may be unnecessary anxiety. Neither of those differences (25 or 50cc) is likely to change your cup size. Additionally, since bras are not all cut the same, some bra cuts may give you a C cup and a different cut bra may result in you needing a D. The bottom line is, if the breast is in balance with the rest of your body habitus it will look great whether its a C or a D.
Breast implants look larger when you try them on
Breasts implants appear larger when you try them on than they do when they are under them muscle. How much larger you need to choose depends on many individual factors and isn't scientific. As a rule of thumb, you need to get 10 - 20% larger, some times more depending your breasts. Seven out of eight women who want a different size after breast augmentation want a larger size.
How To Choose the Best Implant Size For You!
Good communication between the patient and plastic surgeon
is the key to choosing the best size implant for each individual. The surgeon should be willing to work on this for while during the consultation. I allow patients to return for a second shorter consult at no charge if they are concerned about their choice of size.
1. I look at how large the patient is now, how large she was during pregnancy and breast feeding if applicable, whether she has lost volume and what her goal is for her final cup size.
2. I look at the patients height, frame, weight, waist, shoulders, and chest measurements. This helps me understand what range of implants will fit well on this patient and look proportional to her body. Most women want to be larger but proportional.
3. The patient then tries on gel filled implants in a bra and puts on a relatively tight T-shirt to judge how they would look with each size in their range. The also try on high and moderate profile implants. This is a step by step process which takes some time. I ask the patient to say if she feels each size is too big, too small or about right, until we find the one size she likes the best.
Quite often the implant that fits the best by their measurements is the size they naturally like the best. I find women usually know what size looks good on their body and their opinion should be the most important factor in the final decision.
1. The final result often looks slightly smaller so often I tell the patient I plan to add 25 or 30 ml to what they have chosen if they consent to this.
2. Many women make the comment, "I wish I had gone a little bigger" at the 6 month postoperative visit, so I usually suggest if its down to two possible choices, take the larger of the two. This is partially unavoidable because it is human nature to get used to your new size and wonder what if... I have had fewer problems with this by suggesting that women chose the largest of the sizes that they liked when trying the implants on.
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Silicone versus saline breast implants
I find that choosing to go under the muscle and using a silicone implant both are factors in selecting the proper implant size. Silicone implants are underfilled (except for some newer versions used in Europe), and have different tactile and visual aesthetics than saline implants, which are usually overfilled like a water balloon would be if you were trying to smoothen out its edges. I usually compensate by choosing about 25-50 cc more in a silicone implant than I would for a saline implant to get a patient to the same desired size. Going under the muscle makes the slope of the breast more natural in the upper pole, in my opinion, but some of the acute projection is lost if you were to compare it to an implant placed under the gland. Implant projection or profile also has a lot to do with it. For a given base diameter, a moderate profile implant has less projection than a high profile implant. That means that you will look fuller in the superior pole of the breast with a higher profile implant. I commonly use moderate-plus (Mentor) or midrange (Allergan) implants as I feel that they give the most natural results to get my patients to the size they are requesting. I also use moderate profile and high profile implants in select individuals that this would be a better "fit" for to meet their size expectations.
See your plastic surgeon and adequately discuss your implant placement and size .
Ninety five percent or our patients choose to have their silicone implants placed beneath their chest wall muscle (submuscular, also known as the subpectoral plane) and choose implants in the range of 300 cc’s to 450 cc’s. In this range, we usually advise our patients that the muscle may flatten the implants to a small degree and we usually add about 10% to their total volume. Our patients choose their implant size by placing demo implant sizers in a bra.
Most important is for you to engage in discussions with your plastic surgeon covering breast augmentation as it applies to you.
Stephen A. Goldstein, MD
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.