DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

Anesthesia – General, Sedation or Local?

Soft Tissue-Based Planning To Determine Implant Size

What is Soft Tissue-Based Planning?

Soft tissue-based planning means that measurements are taken of the soft tissues (breasts), the tissue characteristics (elasticity, fullness, firmness) are assessed and from this a systematic determination of implant size is made based upon information derived from thousands of previous breast augmentations.  This technique was first described by Dr. Tebbetts. I start with the breast base width. This gives me a starting point from which to work. However, one must consider that when the breast envelope is tight, less volume will fit inside the breast, and when the envelope is lax, more volume may be needed. The other measurements of tissue thickness and stretchability allow me to fine tune the volume estimation. From all these measurements, I can determine the ideal breast implant volume for that particular breast. There is no guesswork with this technique and this method requires that the surgeon pay close attention to many different aspects of the breasts so as to obtain the best possible result.

I have been amazed that since first adopting soft tissue based planning in June 2004, I have on only a few occasions at surgery deviated from my preoperative plan for implant size. The exception is asymmetry cases where two different implants are required. That is an entirely different discussion.

What about placing a bag of rice in my bra?

This is one of the most common ways to select a breast implant. It is also one of the most dangerous. Suppose you had two women with the same size breasts, base width and all, but woman #1 had never had children and had small, tight, perky breasts and woman #2 had lax breasts, having had three children and breastfed each one. Now let’s say each one wears a 34B bra size. You can bet that woman #2 will require a larger implant to properly fill out her breast tissue than woman #1. However, if their breasts are about the same size and they wear the same size bra, then using the bag of rice technique will obtain the same result for each.

This technique is also very imprecise because there is no measuring of tissues involved. I can state from my extensive experience in breast augmentation that using measurements produces much greater precision and more reproducible results than any other technique. The reason the rice technique is dangerous is because it can produce misinformation, which is worse than no information at all, possibly leading to over-augmentation. I believe that I have made a strong case for why measurements are important. The rice method completely ignores your existing breasts, both in size and tissue characteristics. It is complete luck as to whether the rice in the bag method will give you the correct size.

Where does 3-D Imaging fit into the mix?

While most surgeons probably use the 3-D system to help a patient “try on different implants” on a computer, you must realize that to the computer, the breast tissue has endless ability to stretch. In reality, as discussed above, the breast does not. My approach is to first select the implant based upon measurements, and then allow the patient to see what the result would look like for that particular implant. I also tell the patient that the 3-D system is not perfect and that there will be variability between the simulated and actual results. In my experience with the current software version, the actual results tend to look better and are a little fuller than the simulated results. The software is continually being updated and improved to give the best possible simulations.

Although the process of computer simulation is not perfected, my patients still find it useful. As I use a scientifically based system of measurements to guide me in choosing an implant, this 3D system is of little use to me in implant selection; it is really there just for the patient to get a rough idea of how they might look after breast enhancement surgery. In other words, I do not use computer simulation to select an implant size, as selecting an implant size based upon the patients perception of what they think is ideal may lead to selecting an implant that will not fit properly. However, I do find computer simulation extremely useful for conveying to a patient which implant size will result in the most optimal result. The next topic 3D computer simulation of breast augmentation with Vectra 3D will discuss 3D computer simulation and imaging in greater detail.

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