DOI: 10.1097/PRS.0b013e3181cb6530

Patients pursuing breast augmentation have many options to consider before surgery, including surgeon, incision location, pocket plane, and multiple implant factors such as filler type, shape, profile type, texture, volume, and sometimes manufacturer. Implant diameter is another important variable, although it is less obvious to the layperson. Some have additional factors to consider such as the need for a simultaneous mastopexy that can be performed by several different methods and may be unilateral, bilateral, or require a different approach on each side. Ancillary procedures such as correction of inverted nipples or nipple reduction in the postpartum patient are options that add to the decision-making process.

Most patients today conduct considerable research, much of it Internet based, and usually see several physicians before committing to a definitive surgical plan. Arguably the most elusive factor to settle with certainty before surgery is implant size. Many patients have fixed notions of size based either on cup size, celebrity or Internet photographs, the experience of friends (both good and bad), or their personality. However, none of these factors is of proven benefit in selecting the proper implant size.

Verbal communication alone between the patient and physician, even if supplemented with adjunctive information as described above, is an unreliable method for determining implant size. When the decision is perceived to be a unilateral one on the part of the physician, the patient does not feel compelled to accept responsibility for that decision if she is disappointed after surgery. The need for additional surgery for a size change is associated with anxiety, urgency, and the belief that the surgeon is at fault or at least should bear the responsibility for the cost of replacement surgery.
Some surgeons tend to use a size larger than may be necessary to hedge their bets and avoid this situation, often perpetuating the folklore that patients always wish they were a little larger anyway.

Some practitioners have attempted to use a combination of chest wall measurements and “bust circumference” to determine implant size, whereas others have constructed tables that correlate implant volume with bra size for reference.¹,² Others rely on a set of specific tissue characteristics and measurements to determine optimal implant size.³–⁶ Although this latter method seeks to make size selection more scientific, it ultimately presents optimal size to the patient as a fait accompli without participation beyond her anatomy. This does not guarantee a happier patient, although it may provide the surgeon with stronger footing for discouraging pursuit of size change surgery later.

Many experienced surgeons seek to have the patient more actively involved in size selection in a way that will help preview the result. Some have described using rice or saline in a bag to estimate the size of the implant required.⁷–⁹ Today, there are Web sites on the Internet that describe the “rice test” for prospective patients to perform at home.¹⁰,¹¹ A method of preoperative sizing that the authors have been using for the past several years and that constitutes the basis for this report consists of fitting patients with their desired bra size and placing various size sample silicone gel implants in the bra to simulate the result that each size would achieve (Fig. 1). This allows the patient to preview final breast size and, by participating in the sizing process, accept responsibility for the outcome together with the surgeon. The goal is to minimize the prospect for patient dissatisfaction after surgery that can ultimately lead to secondary surgery to change implant size.