My goal in patients with breast symmetry who desires augmentation is to achieve symmetry in volume. This requires relative overfilling of the smaller (usually more “perky”) breast with relative under filling of the larger, (usually more “droopy”) breast. By “relative” I mean the difference in volume above or below what would be considered to be the ideal volume for that breast, assuming that both breasts were of that same size. Let me explain it this way: If both breasts are the same, then I would determine a breast implant volume for the breasts that is based upon the width of the breast and the tissue characteristics that would result in a breast that is naturally filled out, not over or under-filled. This gives the very best cosmetic result with the least amount of postoperative discomfort, numbness, downtime, need for revision surgery and creation of uncorrectable deformities. However, in plastic surgery, there are tradeoffs. If I place the “ideal volume implant” into each of two different size breasts, then I will be placing a smaller implant into the smaller breast and a larger implant into the larger breast. This will result in exaggerating the degree of asymmetry, which we definitely do not want. Therefore, the smaller breast needs to be overfilled and the larger breast is under-filled, essentially a compromise situation. So we are achieving better equalization of breast volume, but shape and “perkiness” will be asymmetric, the degree depending upon the degree of initial asymmetry. By equalizing the volume, the breasts will look fairly similar when supported by clothing or bathing attire. However, when unclothed, the differences in breast contour are more readily apparent. Sometimes, when the degree of asymmetry is not too severe (< 70 cc), the breasts sometimes will look surprisingly similar after augmentation with implants of two different sizes.
As stated before, two different breasts have two different skin envelopes. If one wishes to further improve symmetry in size and shape, then alteration of the breast skin envelope must be considered. This involves removing excess skin from the larger of the two breasts, or dissimilar amounts of skin from both breasts in an attempt to equalize the size and shape of the breast envelope. This will result in placement of a scar around the areola at a minimum and often a vertical scar from the lower portion of the areola (the 6 o’clock position) down to the lower breast crease. Having to perform a breast lift on only one breast and not the other may create a similar size and shape but introduces a new problem; asymmetry with respect to the scars on the breast. This is a judgment call and these options should be discussed with the patient at the time of the initial consultation. I will state that altering the skin envelope at the same time as placement of breast implants (i.e. a simultaneous breast augmentation and breast lift) introduces multiple variables into the equation that result in loss of control of the final result, even when in the very best of hands. This will be discussed in the section entitled: Breast augmentation, Mastopexy (breast lift) and the role of tissue stretch.