This patient has brought up some interesting observations and questions which beg a good and satisfactory explanation. First off, I think its important to differentiate between widely spaced nipples and the distance between the inner edges of the breast, most often referred to as cleavage. And its important to do so because in thinking and talking about treatment, we should identify which things we can and which things we cannot and would rather not attempt to improve. Remember that cleavage can be improved by placing an implant that will be large enough so that the base of the breast comes closer to the midline. That has nothing to do with the nipples, as long as the midpoint of the implant is directly under the nipple. So from this, we can infer that the larger the implant, the better (or closer) the cleavage. SSo then, what size will give the best cleavage? Surgeons have their different ways to achieve this. I rather would like the patient to give me some wiggle room, allowing me to choose the volume of implant necessary to get cleavage. I discuss this with the patient at their consultation and at other meetings prior to surgery but then ask the patient to allow me to pick the size that will bring the volume out to the edge they desire. This, takes away from the patient's thinking mostly about the size and not really connecting with the fact that we are using volume to create shape, and you can clearly see what I mean by that when talking about cleavage. How does the patient know what exact volume will create the cleavage they wish? I have done thousands of augmentations and I dont even know exactly. I can give an educated guess, perhaps plus or minus 30 cc. But I would rather not guess because there a many factors that can affect the volume, like skin and muscle strechablilty. So I actually measure the volume required to get out to that edge, in this case the cleavage area and then I pick the implant that can is that volume. Patients feel more in control when they choose the size, and I also think its very important for the patient to express their wishes, and I would try to achieve their goal, in terms of size. But I think that patients more often express their size wishes but dont really make a connection that there is a range of sizes that can give them the best shape, and that can often be best determined during the procedure, which is why I ask for some wiggle room, perhaps a quarter to a half of a cup size to get the best shape I can get given their anatomy. So lets see both the forest and the trees when talking about breast augmentation and not only talk about the size, but also about what the size does to the patient's shape. Remember, patients have different goals, that you have your specific goals which may be entirely different from other patients goals. So lets talk about everything and not just one thing.The other issue the patient brings up is the issue of nipple placement. The nipple is described generally as sitting in the midclavicular line, a line drawn from the middle of the collarbone straight down. It looks from the pictures that the nipple sits just outside that imaginary line. So an implant would not move the nipple itself as it will stay anchored to the breast. Making the pocket extend farther to the side might give the illusion that the nipplesare less widely placed but I think will help in another way, in that the nipples are not only slightly wider placed (and I would like to say not that bad really), but that they are divergent, or point outwards. Extending the pocket for the implant laterally, towards the side might improve this slightly, making them more convergent and this will also disguise the wideness between the nipples. I have a rule I tell patients which makes them laugh, which is, "the nipples go where the breast goes." The cause of divergence, I think is a little more complicated than just nipple placement and involves how the breast is situated on the chest wall. The rib cage in different patients has differing angulations and you can see in the photosthat the chest bones themself arent flat from side to side but as you move to either side the chest wall itself falls backward. This is totally normal and everyone has some angulation to their chest wall and I see this as part of the natural beauty of the human form, that there are variations in our anatomy. Wouldnt it be boring if everyone were built the same? In fact, you can see that the breasts which are sitting on the chest are also diverging, pointing outwards and an overwhelming majority of women have some degree of divergence which, as I've mentioned has it own intrinsic beauty. I would just like to finish by saying that we are talking about some very specific issues and taking these ideas apart but I think its very important to keep our eye on the ball and to see the big picture which is that breast augmentation has a very high degree of patient satisfaction and that not only can the size be more what the patient wishes but that the shape can be greatly improved. So, in this situation, if more cleavage can be created, more fullness and a better shape and the size near to what the patient wishes, having some divergence is a small thing as compared to the huge improvement gained. I guess I am saying not to get hung up on one thing and see the big picture. I think patients can appreciate and love their cosmetic result in that fashion.
