We welcome Dr. Swanson’s comments regarding our recent publication. We have some reservations, however, with the title of his correspondence and the evidence presented within.
His communication is entitled “Ideal Breast Shape: Women Prefer Convexity and Upper Pole Fullness.” This statement chooses to completely ignore the findings of the population study published in the peer-reviewed article in this Journal.1 It is a statement based on personal opinion backed by no evidence. It is stated in his correspondence that “Mallucci and Branford promote four critical ideals of breast beauty” and that “The authors prefer a linear or slightly concave upper pole.”
The whole point of the population study was to ask a highly mixed population for their opinion—the results are not an expression of our (the authors’) opinions, they are those of the population questioned. The editor of this Journal has produced a video based on this study using photographic images from the publication and carried out an independent straw poll, both of which replicate and validate our findings. It is disappointing, therefore, that Swanson chooses to ignore the evidence presented by the largest population study of its nature. In an era of evidence-based practice, it is questionable how much decision making should be based on personal opinion to the exclusion of peer-reviewed literature. A publication by Hsia and colleagues2 is cited as evidence supporting a preference for upper pole fullness by patients. In this publication, a divergence between patients’ and surgeons’ preferences through a series of sketched linear drawings is the basis of the article: in the study, 13 patients’ and 11 surgeons’ views were compared (in addition to 42 lay people) to come to this conclusion. In our study of 1315 individuals (660 female and 655 male subjects) of all ages, ethnic backgrounds and social class including 53 plastic surgeons looking at photographic images, the conclusions do not support these findings.1 We are in agreement that patients’ opinion and desire are of paramount importance in the decision-making process in aesthetic breast surgery. The work presented gives for the first time objective evidence across a large and varied population group for some consensus on what constitutes breast beauty, thereby allowing surgeons to better understand basic ideals of breast attractiveness and patient preference. It is the verification of an original observational study in a series of topless models selected for the attractiveness of their natural breasts.3
In the third paragraph of his correspondence, it is stated that “if concave upper poles were desirable, corsets and bras would not have been invented”: this is a fundamental subtlety that has been missed by the author that is absolutely pivotal in understanding breast beauty. Women rarely think of their naked breast when they present for breast augmentation, they most often imagine themselves in swimwear or certain tops or dresses where forced upper pole fullness is desirable; however, such fullness does not correspond with attractiveness in the naked breast, as evidenced by the results presented in our study.1 As surgeons, our responsibility is to create the best possible result for our patients in their natural state: how they choose to wear clothing thereafter is up to them, but this should not be the driving force behind the decision-making process.
Our study agrees with Dr. Swanson’s claim that some women prefer full upper poles but only in approximately 14 percent of the population (and only 12 percent of women younger than 40 years). Implant selection and operative planning must be tailored around individual preference, and from our study, this would suggest that anatomical implants, which have been widely used outside of the United States for the past 20 years, would be the appropriate choice in not all but the majority of cases. Dr. Swanson alludes to the fact that some studies have shown difficulty in distinguishing postoperatively between round and anatomical implants. This says more about the study design and the patients selected than it does about the indications for round or anatomical implants. It would be simplistic to imply that there is no difference between round and anatomical implants, especially where there is such a wide range of height/width/projection combinations. Although high degrees of patient satisfaction are reported in Dr. Swanson’s citations, this does not equate to comparative analysis between different breast shapes or proportions: it is quite possible that his patients could have been more satisfied had they been given more objective choices.
The population study changes presumed perceptions on behalf of both the surgeon and the patient. It challenges outdated stereotypical notions of what constitutes breast beauty. Big is not beautiful: beautiful is beautiful. There is universality about beauty that transcends to a great extent the barriers of sex, race, age, and social class (Fig. 1). On the evidence presented, it is not true to say that women prefer fuller upper poles; on the contrary, the natural 45:55 ratio is by far the most preferred and should herald a new era of thinking about goals in breast augmentation and aesthetic breast surgery in general.
The authors have no financial interest to declare in relation to the content of this communication.
Patrick Mallucci, F.R.C.S., F.R.C.S.(Plast.)
The Cadogan Clinic and
Department of Plastic Surgery
Royal Free Hampstead NHS Trust
Olivier A. Branford, Ph.D., M.R.C.S., F.R.C.S.(Plast.)
Department of Plastic Surgery
Royal Free Hampstead NHS Trust
London, United Kingdom
1. Mallucci P, Branford OA. Population analysis of the perfect breast: A morphometric analysis. Plast Reconstr Surg. 2014;134:436–447
2. Hsia HC, Thomson JG. Differences in breast shape preferences between plastic surgeons and patients seeking breast augmentation. Plast Reconstr Surg. 2003;112:312–320; discussion 321
3. Mallucci P, Branford OA. Concepts in aesthetic breast dimensions: Analysis of the ideal breast. J Plast Reconstr Aesthet Surg. 2012;65:8–16
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.