Implant sizing - Rice test and sizers not accurate? (photo)

Thank you for your important question!Your surgeon's recommendations are reasonable.
I always tell my patients that preoperative sizing will
overestimate their post-operative result. Incoming research is showing that
preoperative sizing using a bra has the potential of introducing many unknown
variables resulting in confusion and misleading previews. In fact, by use of 3D
analysis, Costa et al.’s study has shown that preoperative sizing overestimates
postoperative breast volume by 22.3% when the 3D image is superimposed on the
bra-sizer image and that it overestimates upper-pole fullness while
underestimating projection in the lower pole (Costa, Small, & Adams, 2017).

Specifically, the study showed that the bra-sizer image
overestimated the actual breast volume by 20%, while also inaccurately giving
the patient the wrongful perception that breasts will be entirely full in the
upper-pole.
As a patient what you should understand is that the preview
you saw using a sizer is 20% larger than what you will see post-op. For example, if you have 360 sizer, then after surgery, it would seem like you have a 300 cc sized implant. Similarly if you are happy with the 250 cc look, then you will require a 300 cc sized implant to give a similar look. A 400 cc implant will look like the size of 320 cc within the breasts based on 3D-imaging calculations.In the end, your surgeon may be trying to optimally fill your breasts. We never want to make the mistake of going too small as that results in the "rock in the sock" appearance. Your surgeon may use your breast measurements to determine the best size that optimally fills your breasts without increasing the risk of complications associated with large implants. Please engage in open communication with your surgeon and share all your goals and motivations for surgery. Doing so will help avoid post-operative concerns/regrets.Hope this helps.

In most women 150 cc to 200 cc is needed to increase one cup size.  It is not unreasonable to increase the size by about 10% due to compressive forces. Kenneth Hughes, MD, Board Certified Plastic SurgeonLos Angeles, CA

Thank you for your question. "Tissue based planning" relies on your chest and breast measurements and is the safest way to ensure good long term results. Your surgeon should determine what size and projection are necessary to give you your desired result based on your body's measurements. The best way to assess and give true advice would be an in-person exam. Please see a board-certified plastic surgeon that specializes in aesthetic breast surgery. Hope this helps and good luck with your surgery.

implant size
The best way to pick implant size is based on your breast and chest width and not the volume. As the implants get bigger, they get wider. When the width of the implant fits the width of your chest, it will look nice and fit your frame. If the implants are too small, you will have a gap between them and they may look too far apart. If they are too wide, they will make you look top heavy as they may be too wide and stick well out past the sides of your chest. There are ways to get a bigger or smaller look.This can be done by picking a different implant profile. The higher the profile, the narrower the base width of the implant. If someone has a very narrow chest and wants to be big, they should consider a higher profile implant. If someone has a broad chest and they do not want to be too big but want to avoid the gap and still have cleavage without projection, they should consider a lower profile implant such as a moderate. There are options in between these such as the moderate plus. I prefer the underarm approach so there is no scar on your breast. The new silicone is the only way to go as far a rippling as the new silicone ripples much less than saline, especially in the larger implants. I personally prefer the smooth round implants under the muscle placed through the under arm to give you the most natural look and feel. This also leaves you no scar on your breast.  Dr Scott Ennis - Plastic Surgeon – Destin and Miami , Fl

Sizers may be helpful to give your surgeon an idea of how you what to look, but certainly don't translate exactly into what size implant to use.  Going under the muscle, which is certainly the better choice, requires an extra 100-200ccs to achieve the same look that is obtained by simply placing a sizer on top of your breast in a sports bra. I agree with your surgeon on his recommendations for implant size. Looking at your pictures, you have some drooping, more on the right than on the left.  I would suggest that you definitely discuss this with your surgeon before proceeding to avoid being disappointed.

Although useful as rough guidelines and as communication tools, all the modalities currently used to predict what breast implant size/profile will best achieve a patient's goals with breast augmentation are NOT very accurate, in my opinion. The use of the rice test, sizers placed beneath a patient's bra, goal pictures, computer imaging technology… are all useful, but not necessarily as accurate as one would hope.
In my opinion, nothing will replace careful verbal preoperative communication with your plastic surgeon, preferably in front of a full-length mirror along with the use of as many "communication" tools” listed above.
In my practice, I use all of the above modalities and then use intraoperative temporary sizers to help determine the best breast implant size/profile to achieve a patient's specific goals as closely as possible. For this reason, I think it is helpful to have the entire range of breast implant sizes/profiles available in the upper room.
Achieving realistic expectations prior to proceeding to the operating room is also an important part of the preoperative communication process. Patients should be aware that the results of their breast augmentation will not necessarily match exactly what they are visualizing with anyone of the above-mentioned communication tools.
In my opinion, it is not possible to accurately determine how many ccs (if any) a patient would “lose” when undergoing sub muscular breast augmentation surgery. I suggest patients do not make decisions based on statement such as: “you will lose 25 or 50 cc of volume when breast implants are placed under the muscle”. These statements are simply not reliable enough… 
Given your questions and concerns, I would suggest that you schedule additional time to spend with your plastic surgeon. This additional time spent will be helpful in the communication process and in alleviating some of your anxiety.
Best wishes; hopefully you will be very pleased with the outcome of the planned procedure.