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Reply: Bra Stuffing for Implant Sizing? Satisfaction? Who, When, and Compared to What?

Hidalgo, David A. M.D.; Spector, Jason A. M.D.

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Plastic and Reconstructive Surgery: February 2011 - Volume 127 - Issue 2 - p 1002-1003
doi: 10.1097/PRS.0b013e318200ac3f
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Criticism is always welcome as an opportunity for discussion and further clarification of the role of preoperative sizing in breast augmentation. To begin with, the writer implies that progress in medicine over time is strictly linear and that by that measure “four-decade-old subjective methodologies” must be obsolete. What is truly outdated is the model of the surgeon as an autocratic figure that dictates what is best while ignoring patient input beyond presenting anatomy. The trend today instead is toward personalized medicine. Consistent with that, breast augmentation should be viewed more as a couture procedure that intimately involves the patient rather than a purely scientific process focused largely on efficiency.

We disagree with the notion that “up to three visits to the surgeon's office. . .” is a waste of time. If one's core beliefs include that a breast augmentation lasting more than 24 minutes is inefficient, that each minute step of a surgical procedure should be precisely choreographed without variation, and that implant size selection should not take more than 5 minutes, then the value placed on efficiency is disproportionate.1–3 In our experience, seeing patients more than once is mandatory. Patients are often nervous and uncertain at the first visit. They are also usually on their best behavior. Several visits allows the staff, patient, and surgeon to become comfortable with one another (or not) and establish a definitive operative plan.

Although U.S. Food and Drug Administration premarket approval studies may show a 15 to 25 percent reoperation rate, preoperative sizing techniques are not specifically implicated as the source of the problem, as implied. In fact, the vast majority of reoperations today are for capsular contracture, implant malposition, and saline implant deflations. Operations for size change soon after the initial procedure are infrequent, but patient anxiety regarding size immediately after surgery is not. Preoperative sizing has virtually eliminated early postoperative calls in our practice that question size, because the patient has actively participated in the size selection process beforehand. She has experienced a simulation of the final result that includes both appearance in clothes and feeling the weight of the implants, which is not something achievable by tissue analysis and lecturing to the patient alone. Although an imperfect method, it is a far more collaborative tool compared with the practice of having the patient sign multiple consent forms that bind her to taking full responsibility for size before even seeing the surgeon for the first time.4

Preoperative sizing does not ignore an analysis of tissue characteristics and breast dimensions. It is an adjunct, albeit an important one, in allowing the surgeon and the patient to collaborate on selecting an implant size that satisfies her wishes while being respectful of the limitations imposed by anatomy. When the sizing process is complete, there is a narrow size range that will be considered during surgery: perhaps two options, compared with presumably only one determined by the “high five” system. This gives the surgeon some latitude during surgery to make the best judgment based on operative conditions, something the patient willingly accepts and is often grateful for. Our critic has misunderstood the process when he says it allows the patient to “simply choose what they want.”

The writer says that “optimally educated patients rarely opt for bra stuffing size selection.” How would he know? Has he tried it? Does he offer it as an option? Better yet, after scientifically applying the high five technique and determining the exact implant size for the patient, why not let the patient try it on beforehand as an additional adjunct in managing the patient's expectations, not to mention individually verifying a purely numbers-driven size determination?

We are baffled by the assertion that a patient's height, weight, hip width, personality, and even geographic demographics have nothing to do with implant size selection. Even the most doctrinaire methodology must reveal many instances where more than one size will be compatible with a patient's tissue characteristics. These other factors are important determinants in final size selection within the range permitted by the patient's anatomy. Not to consider factors other than breast anatomy ignores the patient as a whole. Furthermore, these factors speak to the artistry involved in breast augmentation, an element that is not served by a purely numbers-driven technique that does not focus outside of the breast base diameter.

It is well understood that too large an implant can result in late tissue stretch and its sequelae. Most of the implants that we use are between 250 and 350 cc, and in postpartum patients, they are typically less than that. We rarely use sizes that begin with a 4, a practice that minimizes late stretch problems. It is also axiomatic that sufficient upper pole fill is a key goal in the postpartum patient. We disagree, however, that a postpartum patient must always be larger than a B cup to achieve this.

To be clear, preoperative sizing is not a precise method and is of course subjective. Improvements in the technique would be helpful and possibly forthcoming. We do not believe that the ongoing advances in three-dimensional patient photography with implant size simulation are the answer. There is no substitute for the patient trying on different sizes and visualizing the effect in clothing and experiencing the implant weight. The method is very instructive in revealing the patient's aesthetic vision in a way that dictating a size based on tissue characteristics alone can never do.

Finally, what can we say to the individual who makes vociferous arguments supported only by his own publications? It logically follows that the ideas of others will not be considered without strong prejudice. We have not witnessed the cognoscenti in plastic surgery today taking up the charge of perfecting choreographed surgery, using the high five system, permitting their patients to go out for dinner, shopping, and dancing on the day of surgery,1 or replicating the perfect record of 50 consecutive breast augmentations without a single instance of reoperation (itself a gift to the plaintiff's bar). Our system operates on a different value system that fosters a collaborative bond between the patient and surgeon, embraces the role of artistry beyond scientific analysis alone, and pursues a unique solution for each patient.

David A. Hidalgo, M.D.

Jason A. Spector, M.D.

Weill-Cornell Medical College

New York, N.Y.


1. Tebbetts JB. Achieving a predictable 24 hour return to normal activities after breast augmentation: Part I. Refining practices by using motion and time study principles. Plast Reconstr Surg. 2002;109:273–290; discussion 291–292.
2. Tebbetts JB. Achieving a predictable 24 hour return to normal activities after breast augmentation: Part II. Patient preparation, refined surgical techniques, and instrumentation. Plast Reconstr Surg. 2002;109:293–305; discussion 306–307.
3. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: The high five decision support process. Plast Reconstr Surg. 2006;118:35S–45S.
4. Tebbetts JB, Tebbetts TB. An approach that integrates patient education and informed consent in breast augmentation. Plast Reconstr Surg. 2002;110:971–978; discussion 979–981.

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