Features
Critical selection
Breast implant selection is not straightforward, particularly when patients have misconceptions about the size of their breasts. Mr Azhar Aslam provides guidance in identifying the best size implants for patients
Breast enlargement is the UK’s most popular cosmetic surgery procedure. The increasing popularity and accessibility of cosmetic surgery has seen a significantly increased demand. Despite the Poly Implant Prothèse (PIP) scandal, few patients truly understand the risks, limitations and long-term effects.
An even more disturbing fact is that, due to lack of proper training, few surgeons beginning their practice really understand the factors and variables paramount in achieving a good, long-term result. Everyone knows that a breast augmentation involves adding an implant onto a pre-existing breast.
However, relatively few surgeons and hardly any patients grasp the relationship of patient desire, expectations and the physical aspects of volume enlargement.
Five dimensions
Cosmetic surgery is unique in that, unlike other surgical specialties, it is performed in a five dimensional framework. To undertake any successful cosmetic surgery operation, an understanding of this framework is a basic requisite. Breast enlargement is no exception.
By “five dimensional” I mean the three-dimensional framework of the (physical) body and accounting for the fourth dimension of time. A cosmetic surgeon has to look into the future to visualise the desired final result after the healing process is complete, taking into account the physical characteristics unique to each individual.
Even more importantly, a cosmetic surgeon has to delve into the patient’s mind to ascertain what the patient dreams of, wants, desires and expects. Understanding this is fundamental to a successful cosmetic surgery operation.
Most patients try to describe their desired result in vaguely defined concepts and unquantifiable terms. In my experience, many female patients are even unaware of what a breast cup size means and how cup sizes are measured. Without this basic understanding, achieving patient expectations may be impossible. Hence, educating the patient to make her understand her own desires and relating them to the limitations imposed by her own body and tissues is the most significant contributor towards patient satisfaction.
For many surgeons and patients, proper implant selection is an art, not a science. No single method has been proven to predict which size or shape will provide long-term patient satisfaction. With detailed patient education, discussion, counselling and respect for implant soft-tissue dynamics, the rate of dissatisfied patients can be reduced significantly.
The goal of augmentation is to improve the size and the shape of breasts. While this creates a more positive self-image, the only predictable change is larger breasts. Positive psychological effects are common but are not necessarily predictable.
At the beginning of each consultation, patients are asked about two elements of what they seek. First, why do they want their breasts enlarged; second, what do they want to achieve.
Understanding the answer to the first question gives a clearer picture of the motivation behind why they are seeking surgery and makes it easy to root out misconceived expectations and to filter out an obsessive element the patients desire. The answer to the second question helps the surgeon to define and quantify the patient’s desire in physical and measurable terms.
Three categories
Patients seeking breast augmentation fall into three broad categories: young patients whose breasts have not grown to achieve “normal fill”; patients, mostly in their 30s, who have suffered the effects of pregnancy-related changes and those related to weight fluctuations; and middle-aged patients, late 40s onwards, who started with small breasts and have changed further because of ageing.
All practising surgeons have come across patients who have complained that their desired cup size has not been achieved. This has been despite the insertion of the desired volume and good aesthetic results.
The discrepancy between a cup size and the volume arises because a cup size is not a scientific measurement and means different things to different people. Patient education is crucial, as almost all patients will indicate the desired cup size they want.
However, if at this stage one asks the patient what she means, almost always it is the case that she does not specifically know the size of a particular cup. Cup size is extremely variable and inconsistent from one brand of bra to another, and it should be pointed out and explained that a cup size is only a general guideline that can’t be ordered or delivered.
Cup size is not a measurement of a particular volume. Rather, it takes into account the volume as well as the dimensions of the breast. Hence, the same volume placed in two women will create a different tissue stretch during healing and settling. This means that the same volume can achieve different dimensions in different bodies and, hence, the importance of tissue characteristics as well as difference of the cup size.
We always point out to the patients that they will be measured as different cup sizes by different shops. As well, if they pick up the same size bras from different manufacturers, these will be different in terms of proper fitting. Hence, the most crucial piece of information that a surgeon must pass to the patient before the surgery—precise cup size cannot be guaranteed.
It is, however, not as despairing as it sounds. With proper measurements and accurate assessment of tissue characteristics, it is almost always possible to choose an implant volume that will match the patient’s desire. That we do not guarantee this to the patient does not mean we do not endeavour to achieve it.
Once the surgeon has quantified the patient’s desire, defining the implant volume is the most important decision. This is the single most important determinant of failure or success of the operation.
The answer to the question— how much breast is enough—depends on breast size in proportion to body size; the characteristic of each woman’s breast skin; and breast tissues. The variables affecting the final breast size are numerous, but the most important are:
• body frame—a breast cannot be seen in isolation as if hanging in the air. It has to be seen always in relation to the body. Hence, assessing the patient’s build in height and weight, and assessing the shoulder and hips provides a basic measurement.
• dimensions of the breast—the base width of the breast is the most important dimension. A second important measurement is the distance between the nipple (NAC) and the inframammary crease (IMC). Others are the distances between both anterior axillary lines and the distance of the nipples from the sternal notch.
• breast tissues—the most important element to measure is the thickness of the breast tissue. This will determine whether there is adequate cover for an implant. Thickness of the tissue should always be judged against the intended volume of the implant. In other words, the bigger the volume, the more the desired thickness.
• quality of breast tissue—thickness of tissue is not enough to provide adequate cover if the quality of these tissues is not good. By quality, I mean the adherence between skin and breast tissue to act as single unit and envelope.
If the skin is dehisced from underlying tissue, the thickness needed to provide cover will have to increase significantly. Every woman’s breast skin can stretch by only a certain amount without sustaining damage, such as excessive stretching and thinning.
• strength of ligaments—it is crucial to understand that any implant adds volume into the breast. This is extremely important in groups two and three, as their breast tissue and ligaments have already been damaged. The stronger the breast ligaments, the more volume they can hold.
• pre-existing volume—it is important to remember, and to remind the patient, that the final volume achieved is the total of pre-existing breast volume plus the volume of the implant inserted.
• patient desire—although this is being listed as the last of the factors, it is the most important. The skill is to reconcile the patient’s desire with the appropriate volume, taking everything into account. This reconciliation may involve a patient’s desire to modify and to create realistic expectations, which will lead to patient satisfaction.
A patient may desire a D cup, but the surgeon may assess the volume needed to achieve the patient’s desire in adding to the pre-existing volume may cause tissue damage. In such a case, a detailed explanation is necessary to change the patient’s desire, or to explain the consequences, in terms of changes in the future and what other corrective surgery may need to be performed if the patient were to fulfil her desires and go ahead with what is seen to be a larger implant.
Trade-offs
No surgical option is without trade-offs. The question is how to maximise benefits and minimise trade-offs.
Perfection or change to a different breast is never an option. Improvement in the existing breast is the only realistic alternative. No surgeon can totally predict what a patient’s tissues will do over time, but every surgeon and patient should consider these issues when making implant choices. No implant will produce the same result in two patients, as already explained.
A range of volumes, instead of a specific volume, will result in a specific cup. For example, in patients with a height range of 5’2–5’7 (about 158–173cm) and a weight range of 8.5–9.5 stones (about 52–58kg), the chest measurements, generally, are 29–32cm. To achieve a C cup in such patients, a volume range of 265–330g is generally needed. The precise volume depends on the pre-existing breast volume, the thickness of tissue, expected tissue stretch and the strength of the holding ligaments.
Similarly, the distance between the NAC and IMC influences the cup size. In the frame range mentioned, a distance of 9–11cm will achieve the basic dimensions of a C cup requirement. This means that, if the distance between NAC and IMC is less, it will need to be increased in addition to an adequate volume.
On the other hand, if this distance is more, the patient should be informed that the cup size dimensions are already bigger than the desired cup—in this example, C. It will be a rare situation when she doesn’t already know this.
In such cases, the loss of volume has resulted in the loss of cup size, but the dimensions are still intact. Hence, a smaller volume compared with the dimensions needed to reduce the cup size. This relationship between dimensions and volume is crucial to understanding cup sizes as generally spoken by patients.
For most surgeons, choosing the correct volume is less of a science and more of an art, based on their personal experiences. Crude methods such as the rice test—in which a patient is asked to try a certain volume of rice in their bras—are commonly used to assist in deciding the correct volume. The main advantage of such tests is not their accuracy but the onus they place on the patients to contribute to the decision-making and in helping them to understand the limitations a surgeon faces.
Identification
Identifying critical variables and decisions to create a simple system to provide surgeons with guidance is desirable. More elaborate
systems, such as a biodimensional system and high-five measuring systems, have been described. But they suffer from the problems of rigidity and uniqueness to the surgeon who created them.
Many surgeons in busy practices find it difficult to adopt such a system 100 per cent, due to their cumbersome nature. A study of such systems can help the surgeon decide the implant volumes more easily, but these are guidelines only and the wishes of the patient still stay paramount whichever system a surgeon applies.
I use a much simpler guideline, essentially based on all factors discussed. For the sake of simplicity, this description is based on only the round silicone implants most commonly used in the UK.
First, the distance between two anterior axillary lines (AA) is measured. Next, the NAC to IMC distance and sternal notch to NAC distance is measured.
Then an implant with the base size of half the AA measurement is chosen. The base size of such an implant will be only slightly larger than the base size of the breast, hence, creating fullness both medially as well as laterally.
The medial fullness gives cleavage and the lateral fullness balances the shoulder and hips and creates the female curviness.
The volume of this implant is noted and based on the patient’s desire, the pre-existing breast tissue, expected change in dimensions and desired shape. This volume is increased or reduced in 20g increments. Almost always, adjustments and ideal implant volume can be found in the ±40–50g range.
Correct cup size
As described, the second important measurement is NAC–IMC distance. In an aesthetically appealing breast, the wider the breast, the longer this distance. Determining optimal inframammary fold position at the end of breast augmentation is a major factor that affects the aesthetic result and achieves a certain cup size.
We take the following general guideline to achieve proper cup size. NAC to IMC 7cm or less provides an A cup; B is 8–9cm; C is 9–11 cm; D is 10.5–12cm; DD is 12–13 cm, and so on. The chosen volume is then inserted with the incision placed according to the measurement given, taking into account any stretch that may take place, hence the volume and the measurement help achieve the desired cup size. This is a simple and effective method. As mentioned, the concept behind this is that, by performing breast enlargement, the whole figure is enhanced. The importance of explaining this to the patient is she understands the breast sits on the body and the operation is being performed to enhance the whole body.
Each individual has her own special needs and desires, and once the volume has been determined, the shape, feel and projection of an implant should be explained. Lastly, the issue of the cup size and the impossibility of guaranteeing a precise cup size should be emphasised.
The main aim of cosmetic surgery is to make a patient happy: this aim should never be ignored for any surgical procedures. My report provides general guidelines, and each patient should, of course, have their own tailored operation.
Mr Azhar Aslam is a cosmetic surgeon at the Linia Clinic, 17 Harley Street, London W1G 9QH
