In all areas of medicine , measurements are needed to evaluate the effects of treatment. In cardiology, an electrocardiogram has served as a valuable measurement device for decades. Even abstract qualities such as intelligence may be measured using a number of instruments, including IQ tests. Unfortunately, breast surgery has long been viewed as an art more than a science [1]. Plastic surgeons have not been in the habit of measuring their results. Regrettably, it is possible, even in 2017, for a plastic surgeon to attend a full day of breast surgery presentations without viewing any measurements on standardized photographs. Instead, surgeons show plenty of before-and-after photographs and discuss their clinical impressions. It has been said that clinical impressions are “what is left in the chair after you get up.” [2] Without measurements, cosmetic breast surgery has lagged in its development. This is particularly true in breast lift procedures, which are discussed in Chaps. 6 and 7.

Measurements used in the past have been largely one-dimensional, such as the distance from the sternal notch to the nipple, or the distance from the nipple to the inframammary fold. One-dimensional measurements are inadequate in providing the needed parameters to evaluate change in breast shape. With advances in imaging and computer software, three-dimensional systems have been developed. Three-dimensional imaging is assumed to represent the future of breast measurements. However, there are problems that have not yet been solved, including the need for a virtual chest wall template .

Aside from lack of a standard measurement system, cosmetic breast surgery has suffered from a lack of a practical definition of breast parameters, such as upper pole fullness , breast projection , and bottoming out. What do these terms mean? A definition of terms is needed.

In 1976, a surgeon from Montreal, Paule Regnault, provided a classification system for breast ptosis [3]. Her classification linked the level of the nipple to the inframammary fold. First-degree ptosis was really no ptosis. The nipple was at or above the level of this fold. In second-degree ptosis the nipple was below it, and in third-degree ptosis the nipple was down-pointing. The concept of linking nipple and glandular position to evaluate breast ptosis is also used by Mallucci and Branford in their 45:55 breast ratio [4]. Eyck et al. [5] incorporate the Regnault classification in their Rainbow scale. The central problem with this method is that glandular sagging and nipple position are two different entities. The combination of ptotic breasts and high nipples, called pseudoptosis, is really nipple overelevation, which is caused by the Wise pattern mammaplasty, the dominant method used in North American since the 1970s. Two parameters are needed – a description of glandular level and a description of nipple level – without linking the two .

Gillies, one of the fathers of plastic surgery , reportedly once said that photography was the most important advance in the history of plastic surgery [6]. One can only imagine trying to judge surgical techniques before photographs were available. We need photographs because they represent the truth without relying on the surgeon’s clinical impression. It only makes sense to standardize photographs. It would make no sense, for example, to take an after photograph much closer to the patient than the before photograph because such a maneuver would unfairly appear to enlarge the result. Similarly it would be unfair to have the patient tilt her chest after surgery to simulate a lift effect. Yet these maneuvers are done routinely and are discussed in detail in Chap. 5.

Zarem [7], in 1984, discussed the importance of standardized photographs. DiBernardo [8] provided guidelines in 1999. Unfortunately, these standards are still widely disregarded at meetings and in the literature [9]. Using the electrocardiogram analogy, this practice would be akin to changing the polarity of the EKG or the time scale on the printout. Such alterations would be regarded as unethical or even malpractice, yet they are tolerated in cosmetic breast surgery. Simply by insisting on standardized photographs, our journals would improve the quality of publications overnight. The number of publications with flawed methods would diminish as investigators learn for themselves the shortcomings of their methods. Plastic surgeons would learn that a breast augmentation does not elevate the nipple [10]. Proponents of the pectoralis muscle loop in mammaplasty would learn that this tunneling method does not really create upper pole fullness after all [11].

A number of points are essential when taking photographs. The focal distance needs to be constant. For this reason a fixed focal length is preferred. To maintain consistency, I have used the same Nikon 60 mm lens for breast and body photographs since I started practice in 1989, simply switching it from an analog camera to a digital camera in about 2000. The same poses are needed and the same arm positions. The chest should not be overly cropped. Care should be taken so that the patient is not tilted. A constant blue background and identical lighting are used. Shadows are avoided by using at least two light sources. A tape on the floor ensures that patients stand in the same place, in the same room.

In order to study my own patients , and to evaluate published results, I developed a new measurement system and definition of terms, first presented at the 2008 meeting of the American Society of Plastic Surgeons [12] and published in Plastic and Reconstructive Surgery in 2012 [13]. I have used this system to study published breast surgery articles [14] and to study my own patients [15–17]. The system turned out to be practical and reproducible. Now I had a benchmark to use to evaluate the results of others and myself. Graf [18] called it an “excellent measurement methodology” and an “important step in objectively evaluating results in breast surgery, especially at a time when there is increasing demand for evidence-based medicine.” Hall-Findlay [19], in her discussion, wrote “If more of us use this type of measurement system, we can provide more ‘science’ to the ‘art’ of plastic surgery.” Nevertheless, this method has not gained widespread acceptance. One lecturer at an instructional course said that if he had to perform all those measurements, he would vomit (I believe he was exaggerating). At a recent meeting, a long-retired plastic surgeon commented to me, “With all those measurements, Dr. Swanson, it’s a wonder you find time to operate.” The irony is that I perform my breast surgery without making any of these measurements. These measurements are made later, to evaluate before-and-after photographs, at a time of my choosing, on weekends, for example. I have found no better way to evaluate my results. Only outcome studies (i.e., soliciting my patient’s opinion, not my own) rival their value.