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No surgical option is perfect. - No surgical option is without tradeoffs. The question is how to pick the option that maximises the benefits and minimises the tradeoffs. Perfection or change to a different breast is never an option. Improvement in the existing breast is the only realistic alternative. No surgeon can totally predict what a patient's tissues will do over time, but every surgeon and patient should consider these issues when making implant choices. No implant will produce the same result in two different patients as explained above.
It is crucial to understand that a range of volumes, instead of a specific volume will result in a specific cup. For example, in patients with a height range of 5'2 to 5'7 and the weight range of 8.5 to 9.5 stones, the chest measurements generally are 29 to 32cm. To achieve a C cup in such patients, a volume range of 265 grams to 330 grams is generally needed. The precise volume depends upon the pre existing breast volume, the thickness of tissue, expected tissue stretch and the strength of the holding ligaments.
Similarly, the distance between the NAC and IMC influences the cup size. In the frame range mentioned above, a distance of 9 to 11cm will achieve the basic dimensions of a C cup requirement. This means that if the distance between NAC and IMC it less than that, it will need to be increased in addition to an adequate volume. On the other hand, if this distance is more, then the patient should be informed (it will be a rare situation when they don't already know this) that the cup size dimension are already bigger than the desired ( in this example C) cup. In such cases, the loss of volume has resulted in the loss of cup size but the dimensions are still intact. Hence, a smaller volume, compared to the dimensions is needed to reduce the cup size. This relationship of dimensions and volume is crucial to the understanding of cup sizes as generally spoken by the patients
How to choose the correct implant volume?
For most surgeons, choosing the correct volume is less of a science and more of an art based on their personal experiences. Crude methods such as rice test, in which a patient is asked to try a certain volume of rice in their bras, are commonly used to assist in deciding the correct volume. In our view, the main advantage of such tests is not their accuracy but the onus they place on the patients, to contribute in the decision making and in helping them understand the limitations that a surgeon faces.
Identifying critical variables and decisions and creating a framework of simple system to provide surgeons with guidance is desirable. More elaborate systems such as bio-dimensional system and high five measuring systems have been described. To us, such systems suffer from the problems of rigidity and uniqueness to the surgeon who created them. Many surgeons in busy practices find it difficult to adopt such system one hundred percent, due to their encumber-some nature. Any practical and adoptable decision process must focus on the few critical parameters that most affect outcomes. However, study of such systems can help the surgeon decide the implant volumes more easily than otherwise. But these are guidelines only and the wishes of the patient still stay paramount, whatever system a surgeon applies.
W use a much simpler guideline essentially based on all factors discussed above. For the sake of simplicity, this description is only based upon the round silicone implants, which are most commonly used in the UK . First, the distance between two anterior axillary lines (AA) is measured. Then we measure the NAC to IMC distance and Sternal Notch to NAC distance.
Then an implant with the base size of half the AA measurement is chosen. The base size of such an implant will be only slightly larger than the base size of the breast, hence, creating fullness both medially as well as laterally. The medial fullness gives cleavage and the lateral fullness balances the shoulder and hips and creates the female curviness.
The volume of this implant is noted and based upon patient desire, the breast tissue and expected stretch with resulting change in dimensions and finally the desired shape, this volume is increased or reduced in the increments of 20 grams. Almost always it is possible to make adjustments and find ideal implant volume in +/- 40 to 50 grams range.
How to achieve the desired cup size.
As described above the second important measurement is NAC to IMC distance. In an aesthetically appealing breast, the wider the breast, the longer this distance. Determining optimal inframammary fold position at the end of breast augmentation is a major factor that affects the aesthetic result and achieves a certain cup size.
We take the following general guideline to achieve proper cup size. NAC to IMC 7 cm or less provides A cup. B cup is 8-9 cm. C cup is 9-11 cm. D cup is 10.5 to 12 cm. DD cup is 12-13 cm and so on. This is a very simple and effective method.
As mentioned, the concept behind this is that by performing breast enlargement, the whole figure is enhanced. It is important to explain this to the patient so that she may understand the breast sits on the body and the operation is being performed to enhance the whole body. Each individual has her own special needs and desire and once the volume has been determined, the shape, choice, the feel of implant and the projection should be explained. Lastly, the issue of the cup size and impossibility of guaranteeing precise cup size should be emphasised.
The main aim of doing cosmetic surgery is to make a patient happy and this aim should never be ignored for any surgical procedures. The description above provides a guideline only and each patient should have their own tailored operation. |
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