Published June 18, 2018 By Dr. Adam Lowenstein

For patients considering breast augmentation, a common question found both on line and in person has to do with implant size. Deciding what size and type of breast implant to use in a breast augmentation can be confusing and daunting, but should not be.

As many know, breast implants can come in various sizes, textures, and shapes. Various surgeons often have preferences in the implants they use, and patients are often presented with these pre-determined “biases”. This can be both good and bad. If your surgeon routinely gets good results, as can be seen in her or his before and after photos, and you are looking for a result that is similar to what you see in those photos, then trusting their preferences and going with their recommendations seems a wise thing to do.

Some surgeons leave much of the decision to the patient, and this can provoke anxiety. An experienced breast augmentation surgeon has seen many breast implants inserted to many patients, and should have a sense of what implant choice is best to achieve the outcome desired by a given patient. Nonetheless, in the litigious environment in which many plastic surgeons work, it can feel more comfortable for the surgeon to have the patient commit to a specific breast implant before surgery. If things don’t turn out as the patient was hoping, the surgeon can then share the responsibility with the patient who chose the implant.

This methodology can lead to significant anxiety by the patient. “I chose 350cc, should I have chosen 370cc?” This question, from the standpoint of an experienced surgeon, is unfortunate. For this example, the 20cc difference between these two sizes is less than 10% of the volume of the implant, and likely far less a percentage of the volume of the whole breast once the surgery is finished. While this 20cc difference is not unimportant to the trained eye of the surgeon, the truth is that a patient will very unlikely recognize the difference between these two implants following the surgery. This small difference is certainly not worth the degree of anxiety that it produces in some breast augmentation patients.

In my practice, I don’t ask the patient to pick the implant before surgery, as I see that as my responsibility. Achieving the patient’s goal outcome is what I find most important, and I do so by using intra-operative sizers to see what each implant looks like when actually in the patient. Pre-operatively, I have patients try on implants in order to show me the size that they want- we take photos of them in a tank top and record the implant size that they used to give them this form. In the operating room, I make the appropriate incisions, and then make the implant pocket. Using the implant size that they chose pre-operatively, I take a sterile “sizer” (a nonpermanent implant of a given size) and place that in the pocket. We then set the patient up to see how that implant looks in that breast. If it looks good and like the pre-operative visit photos, then we know we have the right size. If it looks too small, then we remove that sizer and replace it with one a bit larger. The opposite is done if the breast looks too big with a given sizer- we try something smaller. Each time we change the sizer, we sit the patient up and evaluate. (The patient is asleep through this process, of course.). We are looking for the size that is just right. When we find the right size, then we get permanent new implants of that size and use that for our final augmentation.

While not every surgeon needs to use our methods, we find that we get the size right better than 99% of the time resulting in a happy patient who gets what she was hoping for. This is what works for us. The important thing here is that we don’t leave the responsibility for choosing the implant with a patient who has no experience, no frame of reference, and no ability to make intra-operative judgments. When left to an experienced breast implant surgeon, choosing the right implant should provide a great long term outcome consistent with the patient wishes. This choice should not be a source of anxiety for anyone at all.

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