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Underestimating Implant Volumes in Cosmetic Breast Augmentation

Swanson, Eric, MD

Plastic and Reconstructive Surgery – Global Open: September 2017 - Volume 5 - Issue 9 - p e1483
doi: 10.1097/GOX.0000000000001483
United States

From the Swanson Center, Leawood, Kans.

Disclosure: The author has no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the author.

Eric Swanson, MD, Swanson Center, 11413 Ash Street, Leawood, KS 66211, 913 663-1030, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

The first question to ask in determining implant size is, who makes the choice? It would seem obvious that the patient decides. However, some plastic surgeons believe it is their responsibility to educate their patients about the alleged dangers of large implants and talk them down,1 a practice I have called paternalistic.2 Mallucci and Branford1 warn of serious consequences of large breast sizes, including bottoming out and double bubbles. Like Adams,3 Mallucci’s average implant size is about 290 cc; he considers 400 cc implants, his maximum, “huge” (personal communication, March 2, 2017). Tebbetts4 also believes that implant sizes should generally be under 350 cc. On the other hand, many experienced surgeons insert implants with average volumes in the range of 390–438 cc.2 , 5 , 6 Who is correct?

The second question to consider is whether large implants cause more complications. In my clinical study, there was no correlation between implant size and complications.5 Patient surveys showed a positive correlation between implant size and result ratings.2 Huang et al.6 found that women with implant volumes of 300–350 cc returned for more reoperations than those with implant volumes greater than 350 cc.

The High Five system linearly relates implant volume to the base width.7 A woman with a base width of 10.5 cm receives a 200 cc implant and a woman with a 15.0 cm base width is assigned a 400 cc implant.7 The problem is implant volume is related exponentially (r3), not linearly, to diameter (Fig. 1). This geometric fact means that a woman with a base width of 15.0 cm should receive a 600 cc implant to maintain the same breast proportions as a woman with a 10.5 cm base width.

Fig. 1

Fig. 1

Similarly, tissue-based planning linearly relates the level of the inframammary incision to implant volume.7 Implant surface measurements are related exponentially (1/r3) to volume. Consequently, a linear equation is likely to site the new inframammary fold level too low. The High Five system locates the incision 9.5 cm below the nipple when inserting a 400 cc implant.7 If a supra-inframammary fold approach is used for implants of all sizes (Fig. 2), preserving the inframammary ligaments, the risk of implant malposition, bottoming out, and double bubbles is minimized. Indeed, large implants (> 400 cc) may be blamed when inferior overdissection is the real problem.

Fig. 2

Fig. 2

Bra sizing also tends to underestimate implant volumes (average, 246 cc).2 Computer simulations are not yet reliable because they are not based on actual breast measurement data and therefore inaccurately represent changes in breast dimensions.

So where does this discussion leave us? Not surprisingly, calculating implant sizes without regard for patient size preference using a linear system7 leaves many patients (at least 20%3) with smaller breasts than they desire. Experienced plastic surgeons often show before-and-after photographs of other patients with similar breasts and gather their patient’s input, without tissue measurements, bra sizers, or computer simulations. As Winston Churchill might have phrased it, “it is the worst possible way to select implant size, except for the alternatives.”

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1. Mallucci P, Branford OA. Reply: design for natural breast augmentation: the ICE principle. Plast Reconstr Surg. 2017;139:801e–802e.
2. Swanson E. Prospective outcome study of 225 cases of breast augmentation. Plast Reconstr Surg. 2013;131:1158–1166; discussion 1167–1168.
3. Adams WP Jr.. The process of breast augmentation: Four sequential steps for optimizing outcomes for patients. Plast Reconstr Surg. 2008;122:1892–1900.
4. Tebbetts JB. The greatest myths in breast augmentation. Plast Reconstr Surg. 2001;107:1895–1903.
5. Swanson E. Prospective comparative clinical evaluation of 784 consecutive cases of breast augmentation and vertical mammaplasty, performed individually and in combination. Plast Reconstr Surg. 2013;132:30e–45e; discussion 46e–47e.
6. Huang GJ, Wichmann JL, Mills DC. Transaxillary subpectoral augmentation mammaplasty: a single surgeon’s 20-year experience. Aesthet Surg J. 2011;31:781–801.
7. 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. 2005;116:2005–2016.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.