Dr. Mark Epstein: Welcome! I'm Dr. Mark Epstein, a plastic surgeon practicing in Stony Brook, Long Island, New York. Today I would like to talk to you about my personal approach to breast augmentation. My patients come to see me in consultation because they are looking for a natural looking breast. What a natural looking breast is, is one that is not disproportionately large, nor appear like half a sphere adherent to the woman's chest. Rather, a natural looking breast is one that enhances a woman's shape without overstating it. The outside of the breast breaks up the straight line of the chest wall and balances the hips.

One must keep in mind that a woman's breasts will not accommodate an infinite array of sizes of breast implants. Rather, I believe that there is one ideal breast implant size for each woman's breast. An implant that is too small will give an under filled appearance, on the other hand an implant that is too large will result in a breast that is distorted and overfilled. What we want to do is find that ideal sized implant that gives the most natural looking breast with the proper size. The way I explain this to patients is I say, "Imagine yourself standing in front of a mirror. Place your side against the mirror. Now hypothetically we put a funnel into the top of the breast and we fill with water. As the water is entering the breast you look at your breasts in the mirror. First you'll notice it going from being under filled to being properly filled with a nice shape and size and then being overfilled and distorted. What we want to achieve here is the middle ground, nice shape and an appropriate volume."

So how do I determine the appropriate size implant? I take a very analytical approach. I take detailed measurements of the diameter of the woman's breasts along with the thickness of her tissues and the compliance or stretchiness of those tissues. I start by making an initial volume determination based on the base diameter of the breast. For women who have a very stretchy tissue I add volume. For women who have very tight tissues, I subtract volume from that initial estimate. To better illustrate this, think of a woman who's had three children and has breastfed all of them. Her tissues will most likely be very stretchy and she is going to need more volume in order to appropriately fill her breast. On the other hand, a woman who is 22 years old, never been pregnant, and has small perky breasts with a very tight tissue envelope is going to require less volume, and I might even need to subtract some volume from the initial estimation. This system is actually quite accurate and at the time of surgery I almost never need to change from my initial plan and use a different size implant.

The main reason for taking such an analytical approach to breast augmentation is that the tissues of the breast are respected and protected. Placing an implant that is too large can have substantial negative consequences. First of all, the risk for needing additional surgery goes up substantially. Also, there may be a greater chance of postoperative pain, loss of nipple sensation, bottoming out of the breast, or even deformities that are uncorrectable by additional surgery. Nationwide there is 25% reoperation rate at three years for breast augmentation. What that means is that one in four women who undergo breast augmentation surgery will need some additional surgical procedure within the first three years. This is simply unacceptable. In my practice that rate is approximately 2% and most of these cases that were re-operated were due to issues that were beyond my control and the patients control; such as deflation of a saline implant or capsular contracture of the breast. In my practice I have never had to re-operate on a woman for consequences caused by placing an implant that was too big.

For those of you who select an implant by other methods, such as looking at photographs of a woman who had breast augmentation surgery, placing an implant or bag of water or rice within your bra, or simply selecting an implant from a group of implants on the table, you are eliminating the important variable from the equation of your tissue dynamics and your breast dimensions. By doing so you are gambling by taking a total guess as to which size implant will best suit you.

How to Choose the Proper Breast Implant Size

Dr. Mark D. Epstein discusses his approach with patients for choosing the ideal breast implant size.