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Quantifying the patient desire: the myth of cup size - All practicing surgeons have come across situations when patients have complained that their desired cup size has not been achieved. This has been despite the fact that the desired volume was inserted and anesthetically good results has been achieved!
This discrepancy between a cup size and the volume arises due to the fact that cup size is not a scientific measurement and means different things to different people. In this regard, patient education is crucial, as almost all patients will indicate a desired cup size they want to be. However, if at this stage one enquires from the patient what they mean by it, almost always it is the case that a patient does not specifically know what they mean by that cup size. Cup size is extremely variable and inconsistent from one brand of bra to another and it should be pointed out and explained that a cup size is only a general guideline that can't be ordered or delivered.
It is important to understand that the cup size is not a measurement of a particular volume. It rather takes into account the volume as well as the dimension of the breast. Of these, the two important dimensions are discussed below. Hence the same amount of volume placed in two different women, will create a different amount of tissue stretch during the period of healing and settling. This means that the same volume can achieve different dimensions in different bodies and hence, the importance of tissue characteristics as well as difference of the cup size.
We always point out to the patients that they will be measured to be different cup sizes by different shops. As well as there is the fact that if they pick up the same size bras from different manufacturers these will be different in terms of proper fitting. Hence, the most crucial piece of information that a surgeon must pass to the patient before the surgery. THE PRECISE CUP SIZE CANNOT BE GUARANTEED.
It is however, not as despairing as it sounds. With proper measurements and accurate assessment of tissue characteristics, it is almost always possible to choose an implant volume which will match the patient desire. THE FACT THAT WE DO NOT GUARANTEE THIS TO THE PATIENT DOES NOT MEAN THAT WE DO NOT ENDEAVOR TO ACHIEVE IT.
How the Implant Volume is determined?
Once the surgeon has quantified the patient desire, defining the implant volume is the most important decision. This decision is the most single important determinant of failure or success of the operation.
The answer to the questions how much breast is enough, depends on two major factors:
1) Breast size in proportion to body size
2) The characteristic of each woman's breast skin and breast tissues.
The number of variables that affect the final breast size is a numerous, but following are the most important ones.
- The body frame. A breast cannot be seen in isolation as if hanging in the air. It always has to be seen in relation to the body. Hence, assessing the patient build in terms of height and weight and assessing the shoulder and hips provides a basic measurement.
- The dimensions of the breast. The base width of the breast is the most important dimension. In this regard, a second important measurement is the distance between the nipple (NAC) and the inframammary crease (IMC). Other dimensions which are important are distance between both anterior axillary lines and the distance of nipples from standard notch.
- The breast tissues. In this regard, the most important element to measure is the thickness of the breast tissue. This will determine whether there is adequate cover for an implant. However, most surgeons make the mistake of taking absolute thickness as the important measurement. Thickness of the tissue should always be judged against the intended volume of the implant, i.e. the bigger the volume, the more the desired thickness.
- Quality of breast tissue. Thickness of tissue is not enough to provide adequate cover if the quality of these tissues is not good. By quality we mean the adherence between skin and breast tissue, to act as single unit and envelope. If the skin is dehisced from underlying tissue, the thickness needed to provide cover to the implant will have to increase significantly. Every woman's breast skin can only stretch and enlarge a certain amount without sustaining damage such as excessive stretching and thinning that allows the breast to sag or cause tearing of the skin under surface that produces stretch marks.
- Strength of ligaments. It is crucial to understand that any implant adds volume into the breast. This is extremely important in groups two and three since their breast tissue and ligaments have already been damaged. The stronger the breast ligaments the more volume they can hold.
- Preexisting Volume. It is important to remember, as well as to remind the patient, that the final volume achieved is the total of pre existing breast volume plus the volume of the implant inserted.
- Patient desire. Although this is being listed as the last of the factors, it is actually the most important of them all. Trick is to reconcile the patient desire with the appropriate volume taking into account all the factors above. This reconciliation may involve patient desire to modify and to create realistic expectations which will lead to patient satisfaction.
For example, a patient may desire to achieve a D cup. However, a surgeon may assess that the volume needed to achieve patient desire, in adding to the pre existing volume may cause tissue damage. In such a case, a detailed explanation is necessary to change the patient desire or to explain the consequences, in terms of changes in the future and what other corrective surgery may need to be performed, if the patient was to fulfill their desires and go ahead with what is seen to be a larger implant.
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