How does a doctor determine the max size implant for a patient? Does stretched out skin mean a larger implant can fit?

Question

How does a doctor determine the maximum size implant a patient can do? I’m 5’7 115lbs and have a 28” chest. I have silicone implants under the muscle and are 375cc high profile. They are now sagging, rippled, thinned out. My nipples now are flat and invert depending on my positioning. Does stretched out skin like that mean a larger implant can fit? My skin has always been thin to begin with. What are options to fix distorted looking breast like that? End goal was enormous fake looking breast

Wayne I. Yamahata, MD · Answer

It is difficult to answer your questions without the benefit of photos. But in general, if your breasts are sagging, rippled, and thinned out, larger implants will make all of these issues worse. You would likely achieve greater benefit from a breast lift as opposed to larger implants.

Semih Yildiz, MD, FEPOBRAS · Answer

A surgeon determines the maximum implant size by measuring breast base width, chest width, skin stretch, soft tissue thickness, nipple position, implant pocket, and the quality of the existing capsule. Stretched skin does not automatically mean a larger implant is safer or will look better. In thin tissue with rippling, sagging, and visible distortion, going larger can sometimes make the skin thinner, increase rippling, worsen implant malposition, and accelerate bottoming out.

Common revision options include implant size adjustment, pocket repair, changing the implant plane, capsulorrhaphy or internal support, fat grafting for coverage, and sometimes a lift if the nipple and breast tissue have descended. The right plan depends on an exam and your operative history. Because you mention nipple flattening or inversion, especially if it is new or changing, it is also important to have a breast exam and be current with appropriate breast imaging before elective revision surgery.

Ted Eisenberg, DO, FACOS, FAACS · Answer

After I measure and discuss goals with my patients, we then look at pictures of women (my patients) with similar measurements with different size and style breast implants. They also get to see what they would look like when the breasts have fully dropped and fluffed and in clothes. You get to see actual results and the surgeon's experience and not a virtual idea of what can be achieved. Women tell me that this process is very helpful in determining what size and style breast implant is right for them. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Ellen Ozolins, MD · Answer

Thank you for your question. Your surgeon will determine the maximum implant size based on several factors, including breast width diameter, skin and soft tissue elasticity, the structure of the implant pocket, and the ribcage shape. If the skin is stretched, it can accommodate a larger implant, but thin skin increases the risk of rippling, bottoming out, and the implant's visibility. If your skin is already thin and stretched due to your 375cc implants, opting for larger implants could exacerbate rippling, increase implant visibility, cause the implants to drop too low, and worsen nipple positioning. In such cases, procedures like capsulorrhaphy and fat grafting may be necessary to improve soft tissue coverage and reduce the risks of rippling and visible edges. Consulting with a breast revision expert can help create a suitable plan for you. Based on the examination, the appropriate implant size and profile can be determined, along with any necessary soft tissue modifications, such as a revision lift.

Daniel Barrett, MD · Answer

Dear ashez916,

breast implant type and sizing selection is a complicated process and requires a detailed consultation that includes a discussion of your goals, a detailed examination, and a lengthy discussion. But the decision will always start and end with the patient. 
When it comes to sizing, we have all of our patients find 3 photos of their desired breast size. We ask for naked breast photos because clothing can obscure the true size (push up bras). Next, we consult with patients and go over the photos and take detailed breast measurements during a physical exam. Next, we using a sizing algorithm to determine a range of implants that will work based on the exam and the measurements.
Lastly, during the operation, we use silicone sizers in the operating room to see how the size actually looks in the breast. We sit the patient up in the operating room, while asleep of course, and compare the sizer result with their desired look photos. If it is too small, we start the process over with a slightly larger implant. We don't stop until we get the perfect match.
Of all of my breast augmentation patients, every one of them has been happy with their size due to this detailed and meticulous process. You don't want to invest time and money into a result that is either too big or too small.
You should discuss your concerns with a board-certified plastic surgeon and make sure that your surgeon understands your goals.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Gerald Minniti, MD, FACS · Answer

Regardless, your description was very good, but it does not replace a thorough physical examination to enable a breast revision expert to make a viable plan for you. Based on that exam, an implant size/profile can be determined, along with any soft tissue modifications (revision lift).

David C. Yao, MD, FACS · Answer

Thank you for sharing. The breast implant chosen is determined by a number of factors. Skin looseness is only one factor but know that volume and projection cannot treat all looseness. Patient goals combined with factors including chest size, muscle size (in some cases), pocket capsule, nipple ptosis (low position) are all guides too. The quality and strength of tissue may also play a factor. Some patients believe that bigger size will automatically correct loose skin but that is not necessarily always the case. Stretched out tissues are usually thinner and less able to hold excessive large volume implants over time. A lift or mastopexy may be needed for skin excess and nipple positioning. Internal support procedures may be needed. Talk with a board certified plastic surgeon in-person!

Gary M. Horndeski, MD · Answer

Your implants are under the muscle so the muscle stretches. 375 cc implants behind the muscle are large. It is highly unlikely that you will be able to get much larger implants than that. If you want larger implants then you will have to go in front of the muscle. Remember is your skin is already thin and sagging then the weight of a large implant will stretch out the skin even more and over time the breasts will descend. Unfortunately, you have not provided photographs or told us your bra size. If you are size 32 or 34, each 100 cc of implant corresponds to 1 cup size change. If you are size 36 or 38, each 200 cc of implant corresponds to 1 cup size change. From this, you can determine the volume required to achieve your desired goal. You may need more of a lift than larger implants.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Camille Cash, MD · Answer

An exam is needed for the best recommendation but from your description adding a larger implant to breasts that have excess skin and are already sagging would just make things worse.  A lift will remove excess skin and raise the position of the nipple.  Your surgeon can take measurements of your breasts (different than bra sizing) to determine implants that would fit the space.

James Knoetgen, III, MD · Answer

Determining the maximum size implant for a patient involves several factors, including:
1.	Breast Anatomy: The size and shape of the patient’s natural breast tissue, chest wall, and ribcage are considered. Some women may have more natural tissue or a larger breast base, allowing for a larger implant to fit comfortably.
2.	Skin Elasticity: The elasticity of the skin plays a role in accommodating larger implants. If the skin is already stretched out from a previous breast augmentation, pregnancy, or weight changes, it may have more capacity to stretch further and accommodate a larger implant. However, if the skin has lost elasticity (e.g., after significant weight loss or aging), there may be limits to how large an implant can be safely inserted.
3.	Breast Tissue Health: The amount of natural breast tissue available also limits the implant size. Women with more natural tissue can often go with larger implants without compromising the appearance or health of the breast.
4.	Desired Aesthetic Outcome: The surgeon will also factor in the patient's goals for the look and feel of their breasts. A larger implant may give more fullness, but it also comes with potential risks like the increased risk of rippling, complications with implants (e.g., rupture), or a more unnatural appearance.
5.	Physical Considerations: The surgeon will also consider the patient’s frame, overall health, and how much weight the chest wall and skin can support without causing complications. They also take into account the patient's lifestyle and how an implant of a certain size might impact their daily activities.
A larger implant might be feasible if the skin is stretched, but it's not just about stretching—the skin and tissue must be able to handle the weight and size without causing future complications. A skilled surgeon will typically do a combination of physical exams and imaging (like a pre-operative breast measurement and sometimes 3D imaging) to determine the most appropriate size.

How does a doctor determine the max size implant for a patient? Does stretched out skin mean a larger implant can fit?

Answers (11)

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