Using Pictures to Estimate Desired Breast Size

It is categorically impossible for any patient or surgeon to accurately determine the size of any breast from any picture, unless the picture contains rulers or other measurements of breast dimensions and skin stretch. The two most important quantitative, non-subjective breast measurements to accurately estimate optimal breast volume are the base width of the breast and the degree of skin stretch. Neither of these critically important, objective parameters can be accurately defined from any photograph.

When surgeons and patients view pictures and relate breast size to apparent chest, torso, or body proportions, inherent inaccuracies make these relationships invalid and virtually useless in most cases. The critical parameters of the type of lens used to capture the image and the camera lens to subject distance are usually unknown to patient and surgeon, and are often inconsistent from image to image in a series of breast views. These critical parameters drastically affect visual proportions of breast size and proportional relationship of the breasts to the torso and body.

Assuming that a surgeon or patient “knows” (has an opinion that has no basis in measurement or science) what cup size a breast is in a photograph, the assumption by definition is flawed, because no surgeon or patient can accurately define any cup size by photographic or any other method. If the surgeon allows a patient to believe that the patient can accurately define breast size from a picture, the surgeon is misleading the patient. Whether viewing an image from a magazine or any other source, if a surgeon allows any patient to believe that the surgeon can even approximate a similar result in the patient, the surgeon is selling something that the surgeon may not be able to deliver. Even if the surgeon delivers what the surgeon thinks is a similar result, what if the patient sees the result differently? What if the patient thinks that the result is a bit too large or a bit too small compared to the picture? Once a patient is allowed to fix any image in her mind, nothing a surgeon or staff member can say will ever predictably dissuade her from that image. Nothing is likely to ever convince such a patient that what the surgeon is saying is correct and what she is saying is incorrect.

Photographs allow patients and surgeons to distort or avoid reality. “Oh, her body looks like mine, and if I can just get breasts that look like hers, I’ll be happy.” From the surgeon’s perspective: “She knows what she wants, and I need to deliver it …” (but without assuring that the patient realizes the consequences of her requests over her lifetime). Reality is that the patient’s breasts can only be a larger version of her preoperative breasts. Inadequately informed and educated, the patient will deal with potentially negative consequences of her requests and choices while the surgeon consistently rationalizes, “That’s what the patient wanted.” Allowing the patient to believe otherwise, without optimal information, education, and informed consent process is misleading, and the surgeon is responsible for not educating or misleading the patient.

Using photographs preoperatively encourages patients to ignore their own tissue restrictions, limitations imposed by their individual breast dimensions and tissue characteristics, and focus on a result image that may be unrealistic to assure an optimally safe long-term result with minimal tradeoffs. Patients’ breast dimensions and tissue characteristics never match the tissue characteristics of any other woman in a picture. Instead of focusing on the realities of the individual patient’s personal breast dimensions and tissue characteristics, pictures often distract the patient and surgeon from realities and encourage patient and surgeon to prioritize photographic wishes over tissue realities. The result is often predictable. Instead of acknowledging each patient’s individual tissue characteristics and breast dimensions and selecting an implant to fit and fill the patient’s breast envelope for an optimal long-term result, wishes based on faulty photographic assumptions often encourage surgeons to “force” tissues to a desired result. When surgeons force tissues to a desired result instead of prioritizing soft tissue coverage and filling existing breast dimensions to an optimally safe result, the patient is much more likely to experience long-term tissue compromises such as parenchymal atrophy, chest wall distortions, skin thinning, visible implant edges, and visible traction rippling.

Despite any disclaimers, patients use photographs to shop for their desired result. Using images to discuss possible results is easy, but the practice is inaccurate and misleading. Patients should have an opportunity to view surgeon before and after results, but only to assure themselves that the surgeon can produce a result that is different compared to the preoperative photograph. Any other conclusion or inference the patient draws is largely inaccurate for all the reasons stated previously, and because all surgeon photographs are selected by the surgeon or staff and do not represent a random sample of the surgeon’s results or experience.

Pictures are a poor, inaccurate, and invalid method of defining desired breast size preoperatively. A more realistic method of defining breast size alternatives for any patient is to measure the patient’s breast base width and skin stretch using methods described in detail in Chapter 6, and to demonstrate to the patient the safe limits of her own tissue stretch during the surgeon consultation examination.

Using Photographs to Discuss Possible Changes in Breast Shape

Photographs are categorically inaccurate and misrepresenting as a method of discussing breast size or shape with patients. Photographs are even more inaccurate to discuss and predict postoperative breast shape. While certain implant types and sizes in certain clinical settings may effect shape changes in a breast, shape changes are usually subtle, rarely predictable, and have unpredictable longevity. Every patient should understand that the only guarantee from a breast augmentation is a larger breast and that any other changes that might occur are not predictable and should not be part of patient expectations.

In specific clinical situations such as a patient with constricted lower pole breasts, surgeons can realistically advise the patient what is required surgically to give the tissues a chance to stretch in the lower pole, aided by the pressure of a properly chosen implant. The surgeon certainly cannot predict or guarantee the extent to which any improvements might occur. Instead of showing a patient pictures of an optimally corrected constricted lower pole breast, or even a range of corrections, the surgeon can avoid the patient’s predictably fixing the best image in her mind by assuring in signed documents that the patient acknowledges that the surgeon will attempt to expand the lower pole of the breast, but the degree to which expansion will occur is unpredictable, and that tradeoffs are inevitable. Similar principles apply to a wide range of other breast types and deformities.

Using Photographs as a Decision Aid in Operative Planning

For many years, the author believed that photographs were one of the most valuable tools during operative planning. Developing comprehensive, predictable measuring (TEPID™^,1) and decision support systems (High Five™^,2) helped the author realize that objective parameters and systems are always more helpful, accurate, and valid compared to subjective systems.

Photographs are largely subjective with respect to surgical planning and decisions; measurements are objective. The more any surgeon uses objective measurements and decision support systems, the more the surgeon will recognize that countless aspects of photographic images can be extremely misleading to even the most experienced surgeon.

Even the highest quality, most standardized breast photographs are currently two dimensional. No current three dimensional imaging system has been shown to produce greater reliability, reproducibility, or decision support in any valid scientific study. The breast is three dimensional. Photographic images are static, and do not reflect dynamic parameters of the breast tissues that directly impact critically important decisions in breast augmentation. The most important of these dynamic characteristics is skin stretch. Two different patients’ breasts may appear virtually identical in a picture, but the degree of measurable skin stretch may differ dramatically between the patients. A correct decision based on photographs in one patient, therefore, is a suboptimal or incorrect decision in the other patient.