I spoke with a woman during a consultation for a breast augmentation who said that she had encountered numerous statements written (on the internet) by women who had breast augmentation surgery and wish they had “gone bigger”. She then asked if I ever encouraged women to select larger-sized breast implants right from the beginning. She was considering implants in the 450 cc to 500 cc range.

This woman was 28 years old, 5’ 1” tall, and weighed 125 pounds (after a 15 pound weight loss). She had a small breast, about a large A-cup size, with volume loss. The base width measured about 11.5 cm. She desired augmentation to a full D-cup size and thought about 450cc would be what she desired… So the implant size she was considering was very large, and would require an implant with diameter that was at least 1cm (or more) greater than the width of her breast. In addition, she was worried that 450 cc would not be big enough, and was questioning whether she should just go with 500 cc right away so that she was not disappointed.

My response to her went something like this….

Selection of an appropriate breast implant size does vary with a woman’s body habitus. A 260cc breast implant may give a petite woman a D-cup size, but this same size would be insignificant for a woman who is tall and muscular. For the majority of patients, a 500cc breast implant is BIG. For someone with this patient’s small frame and breast size, this volume implant is even BIGGER. For the average size woman, a “large” implant probably begins at 350cc. This definition of “large” is based upon the biomechanical stress that the implant places on the breast tissues; it is these stresses that affect and alter the breast over time. The larger the implant volume, the greater the stress placed on the breast tissue and skin.

There is significant morbidity associated with large implants: the formation of stretch marks, excessive skin stretching, skin thinning, palpable or visible wrinkling and rippling of the implant, implant descent below the level of the inframammary crease, a double-bubble deformity, breast drooping, pseudoptosis, atrophy of the breast tissue, etc. Some of these problems may occur shortly after surgery, while others may develop over several years. Regardless, these changes in the breast are sources of patient unhappiness, complaint, and dissatisfaction. From a surgeon’s perspective, adequate surgical revision or correction for some of these problems is often very difficult, or some times not possible.

I follow a dimensional planning philosophy when I select breast implants. I utilize measurements of the breast along with tissue compliance to estimate the appropriate implant volume. Utilizing dimensional planning means that the breast implant diameter does not generally exceed the base-width of the breast, and that tight skin envelopes require smaller implant volumes to avoid over-stretching the skin. Even though lax skin envelopes can accommodate larger volume implants, that does not mean that an extra large implant must be used to fill the breast; and instead a breast lift can be used to tighten the skin and shape the breast after a more moderate implant is placed.

An individualized approach is required for each patient evaluation. Since informed patients tend to make good decisions, a comprehensive consultation that presents honest information is a very important part of the entire breast augmentation process. It is important to understand the patient’s desires, but it is equally important for patients to understand the benefits of dimensional planning.  The dimensional planning philosophy produces a natural breast, minimizes morbidity and associated re-operations, and provides better long-term results.

So in the end, large implants are not all they seem to be. A good and lasting result, free from problems, is what really matters.