DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

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Choosing The Right Breast Implant Volume (Size)

How To Choose The Right Breast Implant Size

Almost everyone who comes to see me in consultation is most concerned about size. Why not? You are coming to see me to enlarge your breasts, so the obvious question is “how large is large enough?” This is one of the most important questions. You, the patient has an idea what you like. Maybe you are unsure of what is the right size. Surgeons have different ways of selecting implant size. Certainly, in every case, the surgeon MUST listen to the patient and at the very least understand what it is that the patient wants. Maybe the patient’s desires are feasible, maybe they are not. It is absolutely essential that the surgeon know how to select the correct implant size so as to enhance the breast and at the same time minimize the risk of complications and need for re-operation. This section reviews the rationale for proper implant selection, how to maintain a “natural” look, discusses scientifically proven methods in implant selection.  3D imaging and computerized simulation aid in the consultation process and implant selection. This will be addressed later on.

Good, Quick and Cheap: You can have two but not all three…

If you ever dealt with a contractor, you know you want work done quickly, you want it done well and you want to pay as little as you possibly can for the work. This is only human nature. Most contractors will tell you that you can have any two, but that it is impossible to have all three. In the world of breast augmentation, many women want to go large, but they want to still look natural. The fact of the matter is that once you start exceeding the natural limits of the breast tissue, distortion of contour arises along with other issues that can result in significantly increasing the risk for revision, and worse yet, creating potentially uncorrectable problems.

It cannot be emphasized strongly enough that if you want the best possible looking breast with the easiest recovery and the least chance of problems leading to re-operation, then selection of implant profile and size must be in accordance with the characteristics of your tissues. Any attempt to force your tissues to bear a size and/or shape that are beyond the limits of your tissues will be accompanied by an increased risk of tissue damage such as breast tissue atrophy and overstretching, and the creation of potentially uncorrectable deformities. Despite what anyone, including another plastic surgeon, might tell you to the contrary, this is true whether I or any other surgeon performs your surgery.

When I measure your tissues, I will determine what I believe under the circumstances to be the most ideal size (in cc’s, which is a standard measurement, not cup size which is nebulous and not standardized) implant for your breasts. It may be that this number is very similar to that of an available size implant. If that is the case, then that size implant is the best size for you. If the optimal size determined by me falls between the size of two available implants, then most likely, you can achieve a similarly good result with either size implant as the difference in volume of either implant from your ideal volume is relatively small.

I am occasionally asked if I will use a volume other than what I feel to be the best for your breast tissues. If I use an implant smaller than what I measure, the potential untoward effect is usually just cosmetic in nature; the implant may not look large enough for your breast. Usually I can drop down one, two or three implant (not cup) sizes without too much of a problem. However, if I am asked to use a larger implant than I feel is optimal for your tissues, the situation is very different. If I believe that the size requested is so large that I have to worry that the wound may break apart, or that I will do severe damage to your tissues, or will produce a result that is not what you are requesting (especially if you want a natural result) than I will not proceed using that size implant. If I feel that your breast will accommodate the requested size implant, but that there may be more of a risk of numbness, pain, longer recovery, overstretching of the lower part of the breast (usually more of an issue in women who have not had children or have a tighter breast tissue envelope), then I will agree to proceed, but you will be advised about those increased risks.

Do I lose cases at consultation because I cannot (or will not) produce certain results as requested by the patient? I am sure I do, but I know in my heart that I am following my duty to advise the patient appropriately and to not perform any surgical procedure that I believe is not in the patient’s best interests. Looking at it the other way, in my practice, using the thoughts and processes as discussed on this web site,  it has been extremely rare for me to perform a breast augmentation only to have the woman dissatisfied with the size and request a revision to a larger size.


If your goal is a natural appearing breast, then breast augmentation is not simply a matter of creating a pocket for the implant and then placing any size implant that you deem desirable. That is a “recipe for revision”. My goal is to perform surgery that will not need a surgical revision for a very, very long time, hopefully never. The way to achieve this goal is to fit the implant to the breast.

In all my breast augmentation surgeries, no matter what the type of breast (I or II), the goal is to select the proper size implant that appropriately fills out the breast. What does this mean? Dr. Tebbetts, in his book The Best Breast 2, makes a great analogy: Let’s say, hypothetically speaking, we have you stand up in front of the mirror. We place a hole in the top of the breast (think of it now as an empty bag) and insert a funnel. I pour water through the funnel into your breast. You watch in the mirror as your breast slowly inflates. It will go from under filled to looking really great, the most natural shape possible (I call this “properly filled”) and then we add a little more water. The breast will start to look rounder, tense and unnatural. This is what an unnatural augmentation will look like. And that tense feeling? Imagine that pressure on your breast tissues 24/7. That can’t be good for the tissues. That is how the breasts get damaged, overstretched in the lower pole and deformities get created. Furthermore, the risks of excessive tissue stretch, pain, loss of nipple sensation, and need for surgical revision will increase substantially if the breast is over-augmented.

Ok, so we now have identified the “proper fill volume”. Well, we can’t put a funnel into the breast during the consultation, so how do I determine the “proper fill volume” before surgery? Fortunately, there is a way. Dr. Tebbetts created a system based upon his experience with hundreds of augmentations, in which measurements are taken of the breast, and based upon this data, the ideal volume can be determined.

My approach, which I credit to Dr. John Tebbetts, is a bio-dimensional approach coupled with an assessment of the tissue characteristics. First, the base width of the breast is measured. This is a starting point for selecting the base diameter of the implant. Next, a thorough analysis of the tissue thickness, and compliance (stretchability) as well as key measurements of proportion are assessed. A breast that has a tight skin envelope will require less fill volume than one with a normal skin envelope. Conversely, a breast with a lax skin envelope will require more fill volume than a breast with a normal or tight envelope. I can also precisely lower the breast crease, if necessary. Thus, this approach will allow me to produce an augmented breast with the most natural appearance, the least chance of undesirable overstretching, the least discomfort, least risk of loss of nipple sensation, least risk of atrophy of the breast tissue, and least chance of requiring a revision in the future.

The beauty of this system is that it truly works, and is reproducible by other surgeons who follow it. I began using this system in 2004, and now well over one thousand augmentations later, I can clearly state that the system does work. How do I know? I know because the patients look natural, properly filled after surgery, patient satisfaction is extremely high and I have only very occasional requests to use implant sizes other than what I deem to be optimal for a given patients tissues.


The left two breasts are underfilled, the right three breasts are overfilled. only the third breast is properly filled.

Benefits of Choosing the Proper Implant Volume to Fill Your Breasts

So, besides achieving the right look, what are the other benefits of choosing the “proper fill volume”? Remember the “proper fill volume” is the volume that the breast will comfortably accommodate to fill out the tissue. If you properly fill out the tissues, then you are not going to overstretch them. The result is longevity of the result, minimal risk of distortion, less discomfort after surgery, less numbness in the nipples and breasts, as well as having a negligible chance of needing a secondary surgery (the dreaded “revision”).

Once a breast needs a revision to correct a problem, the chance of success of that revision achieving the initially desired result is less than the chance of achieving that same result with the initial surgery. And so, with each revision, the chance of needing further revisions increases. Just go to www.implantinfo.com and read the pre-op forum stories. You will see question after question about patients requiring revision. In my practice, my 3 year re-operation rate (hematoma, revision, or a size change) is about 2%, compared to national rates of 15 – 40 %. So when considering cost, downtime, lost wages from re-operation, clearly, achieving a natural result and a negligible re-operation rate is very desirable.

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