Choosing The Proper Fill

*Individual results may vary

OK, so now you understand what type of breast you have, how do we proceed from here?

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 a 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 a chart, 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 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 Fill

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 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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Epstein Plastic Surgery Long Island NY

Mark D. Epstein, M.D., F.A.C.S.
200 Motor Parkway, B12
Hauppauge, NY 11788