Why Don't Doctors Encourage Women to Go Bigger?

For most patients, 500cc implants are big. In fact, for the average sized patient, if considering the biomechanical stress of an implant, a “large” implant probably begins at 350cc - 400cc. But implant size does (need to) vary based upon body habitus. A 260cc implant may give a petite woman a D-cup, but be insignificant for someone who is a muscular 5’10” tall.
There is significant morbidity associated with large implants: excessive skin stretching, the occurrence of stretch marks, aggravated implant descent below the level of the inframammary crease, thinning of the skin, wrinkling and rippling, breast ptosis, pseudoptosis, breast gland atrophy, etc. Some of these may occur soon after surgery, while others may occur in a more delayed fashion or over several years. Either way, these are sources of patient dissatisfaction, and the surgical correction is not always easy.

I do involve the patient in their implant sizing, but I prefer to follow a biodimensional philosophy for implant selection. I utilize measurements and other assessments of the breast-skin envelope to estimate the appropriate sized implant. This means that the diameter of the implant does not generally exceed the base width of the breast, that small tight skin envelopes require smaller implant volumes, and that more lax skin envelopes can accommodate larger volume implants. But in light of the potential morbidities listed above, just because there may be significant breast deflation and laxity does not mean that a large implant must be used to fill the breast back up; and so I am not afraid to also use a lift in those situations.

A successful operation, and a happy patient, is the result of good communication. I have detailed conversations with my patients regarding sizing, their desires, and the reasons why I believe biodimensional planning is important. I have patients perform sizing at home and/or in the office, and I also use intra-operative sizing to help make decisions.

My approach is individualized to each patient. I believe this approach minimizes stress to the breast, minimizes morbidity and associated re-operations, and yields better long term results. Utilizing this philosophy, I have re-operated on only two patients in the last twelve years to place larger implants; these re-operations were more than two years after the initial augmentation.

I know I don’t make the biggest breasts around…and I’m okay with that...and I know my patients are as well.

Best wishes, Ken Dembny

Your anatomy is the absolute limiting factor of what can be achieved, not your wishes (or even a surgeon's preferences or biases). The latter is evidenced by the differences in opinion in the answers, and your wishes should be foremost, though of course are subject to the limitations of your anatomy. However, since anatomical limitations are defined differently by each surgeon, this is what makes differences in opinion. This is one of those issues that is not black and white, but many shades of gray!

Experience with thousands of women requesting breast augmentation over several decades has shown me that all the crepe-hanging and naysaying about "big implants" are (mostly) justifications for a particular surgeon's point of view: "Large implants thin the tissue" or "Larger implants will require more surgery down the road" or "Large implants have more (rippling, heaviness, complications, drooping, etc. etc.). "Therefore, you must do what I say rather than what you want."

While there may well be a grain of truth in all of these statements, it would be like having your plastic surgeon concentrate his discussion for elective surgery on: "There could be infection" or "You could have a heart attack" or "You could die." All true, but come on! Do you really need to have this be the main focus of discussion?

The reality here is that your height and breast anatomy must go hand-in-hand with your goals AND your surgeon's skills in order to best achieve your desired result. If you have ascertained that you might want to go somewhat larger than a certain recommendation, and if you can communicate this to your surgeon, trust that s/he truly understands and accepts your request, and then trust that s/he will do the utmost to accommodate your request within the constraints of your anatomy (and will use the largest and best-match profile for your anatomy and goals), then it is certainly OK to choose large(r) implants.

And well within your rights to request this of your chosen surgeon, or find another experienced ABPS-certified plastic surgeon who will follow this plan. For examples of my breast augmentation patients who have implants of 550cc or larger, click on the web reference link below and look at cases 12, 24, and 31 (and compare these implant sizes to the other patients and their implant sizes). You will find that "average of 350cc" just has no meaning when you are individualizing surgery for each patient's goals and anatomy. Best wishes! Dr. Tholen


 

When it comes to choosing breast implants, I leave the size up to the patient and I just guide them along in deciding what size is best for them.  If you think 500cc is right for you, then you should get 500cc implants!  I usually take a lot of time with my patients in determing the best size as this is a very important decision.  We take implant samples and place them in the bra to get an idea of how they will look after breast augmentation.  In addition, we look at numerous photos to see how different implants sizes look on other breast augmentation patients with similar bodily dimensions.  Either way, you should be happy with your decision and in your case you may need to get a second opinion.  Good luck!  Dr. Schreiber...Baltimore plastic surgeon

500cc's on one petite body frame can be very large, but on a larger frame can be swallowed up by the surrounding tissues.  I encourage all my patients to spend time during the consultation and pre-op process to "try on" implants so that there is no mis-understandings after surgery.

Surgeon's goal should always be making sure the patient is happy in the long run. Sizing of implants are done in many ways. But you are right, in trying sizers for the first time most patient will choose a size that may appear too small to them a year later. It is always best to pick a size that is slightly larger than what feels right. There are exceptions that must be considered.

 

    You will find some plastic surgeons who are very conservative in size recommendations and may prefer to place 250 cc to 350 cc in every patient.  I just listen to the patient, determine how much larger they want to be, have them try on sizers, and place the same size implants as the size they select within reason.  Kenneth Hughes, MD Los Angeles, CA

A happy patient is the goal of most surgeons. Getting exactly the size the patient wants can be a little tricky. I have my patients do the "rice test" which helps them visualize how they will look. Uncooked rice is placed in a nylon stocking and tied into a knot. A woman can test out the sizes and weights of the various sizes of implants by placing them in her bra with her own breasts.Patients who have used this method have a high satisfaction rate with the implant size they ultimately chose. It is the surgeons job to help direct the patient to get the right size the first time. Going too large can result in looking disproportionate or top heavy. Going too small may leave you wishing you had chosen a larger size the first time.

The short answer is, patients don't WANT to go bigger - initially.  We all see this.  Women undergo breast augmentation because they are unhappy with their breast size.  I have patients try on implants from very small to very large then we work our way to what looks the best.  Most patients are happy but a small number think every pair of implants look too big.  Even if I tell them the implants will still keep them proportionate they are afraid they are too big.  I take into account the patient's personality, activity level, body proportions etc.  before I make my recommendations.  But, still in about 5% of cases patients decide on their own. 

Once the augmentation is completed and the patient get used to them, that's when they think they could have gone bigger.  So although we can give our professional opinion it is ultimately up to the patient to decide what size implants she desires.

I almost never find my patients asking for larger implants after having surgery. I think it is because after I examine them and select an implant I then have them do a baggy test.  After the baggy test adjustments of volume are sometimes made.

The real issue is long-term support for the weight of the implant. During surgery the implants are placed into a space created under the breast gland or both the breast gland and pectoralis major muscle of the chest. With the possible exception of "shaped" cohesive gel implants, which have a textured surface, a patients body will not "grow into" the implant. So consideration has to be given the long-term support of the implants, which is provided by the ligamentous tissue in the breast. Large implants are heavier, and the ligaments supporting the implant may have to be divided to make room for a larger implant. This may result in the implant moving into a position that looks un-natural (like the armpit when laying down). Correcting this will require a significant surgical procedure.

My advice to patients is to choose a size implant that closely fits the dimensions of the existing breast diameter. This way you are ensuring that you will have a full, beautiful appearence that will stay that way for a long time!