Richard T. Bosshardt, MD

Dear Claire,

There are several aspects to your question that must be considered. You are clearly a small person so you don't want implants that are too big, making you look unnatural and even, potentially, freakish. Most of my patients do not want to be "showy" but they want to see a difference, in and out of clothes.

After 20 years of practice, I know of no way to pre-size patients accurately in advance of surgery. Simply stuffing implants into a bra tells you nothing about what they will do for you in your breasts- the situations are not comparable. Computer programs cannot take into account the many variable found from one patient to the next in terms of skin elasticity, breast tissue quality, and more. I have found that using breast sizers intraoperatively works best. These are reusable, adjustable breast implants that can be inserted into each breast once the preparation of the implant "pockets" is completed. The sizers can be filled to whatever size desired to see how the breasts look and feel with an implant in them. Some judgement is necessary to be able to visualize the results months down the road. This requires that patients communicate their desires clearly to their surgeon and trust that the surgeon will follow this to the best of his or her ability. Surgeons must also clearly explain the limitations of the surgery.

There is no standard for what an A, B, C, or D cup is. Each manufacturer makes bras according to their own standards and these vary greatly. Using cup size alone as a measure of the surgery is a set up for disappointment. A natural, well proportioned appearance with minimal risks of problems should be the ideal. The best size implant will be greatly determined by what each patient brings to the operating table, literally. I have found that when patients choose their own implant size, they are often disappointed, and usually by choosing too small.

The issue of implant style is interesting and I feel that too much is made of it. The majority of implants used in the U.S. now are round, smooth, moderate profile implants because these produce the best results in  most women with the fewest problems. High profile implants are useful in patients with narrow chests who need or desire more projection with smaller volumes. I rarely use any other style of implant. I do not like the textured or anatomically shaped implants (also called "tear drop" shaped). They have too many problems that I do not want to deal with.

I hope you are successful in achieving your goals. Don't be afraid to ask a lot of question, ask your surgeon to explain his or her recommendations, and, if necessary, seek another opinion.

Sincerely,

Dear Amanda,

Yours is a very interesting case. Each of your breasts is attractive taken on its own so you have to decide what result you want as this will determine the best operation for you. For what it is worth, my feeling is that if you can be happy with your breasts without resorting to implants, you are better off as these usher in a whole set of concerns that will not be there if you don't use them (hardening of the breasts, failure of the implants, visible or palpable rippling/wrinkling, etc. ) This would mean surgery on the larger breast to reduce it and, possibly, a small lift on the left. If you prefer the larger breast, an implant will be necessary on the left to enlarge it but you will be very unlikely to get a symmetrical shape as the implanted breast may not look at all like the natural right one. There are several things you need to understand:

1. When you start with very asymmetrical breasts, you will always have some element of asymmetry. To expect a perfect correct by anyone is to set yourself up for disappointment.

2. Reductions and lifts are similar operations with similar incisions. The difference is that in reductions, breast tissue is removed to make the breast smaller while in lifts this is not so. Lifts will make any breast more compact so that even when no breast tissue is removed, the lifted breast may not fit a bra in the same way and cup size may even go down.

3. The bigger the implant you choose, the more likely your breasts are to look and feel unnatural and the more potential for problems now and in the future. 400 cc implants are large by any standards and your left breast is not that small.

4. Cup size is one of the least reliable ways to describe breast size. No two manufacturers make their cup according to the same standards so you may fit a B cup perfectly in one bra and an A or C cup in another. I rarely rely on cup size when telling my patients what they may expect. There is little correlation between the number of cc's in an implant the final bra cup size. It depends on where you start. Victoria's Secret sizes all their bra larger than about anyone else. I have patients wearing a C cup from one major manufacturer and DD's from V.S.!

5. Your goal should be improvement and not perfection. Aim for breasts that will fill a bra reasonably evenly so that you may wear bathing suits and summer clothing without feeling self conscious. Making them look good when exposed is and ideal to shoot for and, if achieved, is "icing on the cake".

Good luck with whatever course you choose.

Adrianna,

Your concern about your areolae is understandable. It may reassure you to know that perfectly symmetrical areolae are uncommon. Areolae that are too large or not positioned symmetrically can be corrected but it is important to be sure that the correction will not create worse problems. The only way to re-position or down size an areola is to make an incision all the way around it. This will leave a visible scar and the margin of the areola will forever be unnaturally sharp and round, as opposed to the normal, where the color tapers off at the edges. Even if the scar is very faint and fine, it will be clearly visible. If the scar is anything but this, it may look quite unattractive. No surgeon can guarantee the quality of the scar in any patient. To maintain the smaller size of a reduced areolae we often have to use a permanent "purse string" suture that runs all the way around the edge of the areola. This may be felt under the skin as a palpable band, and may produce an unnatural bulging of the areola. Some areola reductions may leave "pleats" in the skin that will be permanent. In the photos you sent, your areolae are not excessively large or malpositioned. They are slightly assymetrical but I would hesitate to try to move them. I feel it is better to have breasts that may be slightly assymetrical yet look entirely natural, than perfectly symmetrical breasts (very difficult to produce surgically) that have an "operated upon" look with visible scars. Cutting around the areolae carries the risk of losing sensitivity in this important area and may even impact the ability to breast feed. It has been my experience over 20 years of practice that women are their own worst critics and much more critical of their breasts than their husbands or boyfriends.