What Is the Ideal Breast?

Smaller or larger? Full cleavage or subtle cleavage? Pendulous or perky? More fullness in the upper pole or the lower pole?

We should not be too surprised, in view of the purpose of bras and corsets before bras, meant to augment the upper poles of the breast. Few, if any, Greek statues portray a sagging or deflated breast!

An upper pole/lower pole ratio of 45:55 (or 0.82) has been promoted in the plastic surgery literature (Mallucci P, Branford OA. Plast Reconstr Surg: 2014;134:436–447). This ratio calls for more fullness in the lower poles of the breasts than in the upper poles. Shaped implants are designed with this shape in mind. However, this ratio, 45:55, is also the same as the ratio among women choosing to have a breast lift, who have sagging breasts to start with.

After breast augmentation, this ratio is closer to 1.6:1, and these patients report very high levels of satisfaction, 98.1%. Plastic surgeons need to remember that women desire ideal breasts, not necessarily natural-appearing ones (there being nothing more natural-looking that sagging breasts).

Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg. 2013;131:802e–819e.

Swanson E. The ICE principle, 45:55 breast ratio, and 20-degree nipple inclination in breast augmentation. Plast Reconstr Surg. 2017;139:799e–801e.

What Is the Ideal Breast?

Smaller or larger? Full cleavage or subtle cleavage? Pendulous or perky? More fullness in the upper pole or the lower pole?

Among patients presenting for a breast augmentation, there is a consensus. Most women prefer more fullness in the top part of the breast. This is despite the fact that the normal breast typically is fuller in the lower pole. (Hsia HC, Thompson JG. Plast Reconstr Surg. 2003;112:312–320). We should not be too surprised, in view of the purpose of bras and corsets before bras, meant to augment the upper poles of the breast. Few, if any, Greek statues portray a sagging or deflated breast!

A ratio of 45:55 (or 0.82) has been recently promoted in the plastic surgery literature (Mallucci P, Branford OA. Plast Reconstr Surg: 2014;134:436–447). This ratio calls for more fullness in the lower poles of the breasts than in the upper poles. Shaped implants are designed with this shape in mind. However, this ratio, 45:55, is also the same as the ratio among women choosing to have a breast lift, who have sagging breasts to start with. (Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg. 2013;131:802e–819e.) After breast augmentation, this ratio is closer to 1.6:1, and these patients report very high levels of satisfaction, 98.1%. Plastic surgeons need to remember that women desire ideal breasts, not necessarily natural-appearing ones (there being nothing more natural-looking that sagging breasts!).

What Is an Appropriate Breast Size?

Most women prefer larger breast sizes over smaller sizes. Of course, too much of anything can be detrimental, by definition, and very large breasts are undesirable to most women. The desired breast shape is parabolic in the upper pole, the shape of an umbrella held forward, and semicircular in the lower pole. Loss of fullness in the upper pole and excessive sagging of the lower pole are common complaints and universal ones, regardless of age, race, or culture.

Plastic surgeons have, historically, often been conservative in their size recommendations, and many are reluctant to insert large implants (implants > 350 cc). There is a perception that such sizes increase the complication rate. However, outcome studies of my patients actually show a positive correlation between implant size and patient satisfaction, and no increased risk of complications. Today, my average implant size is just over 400 cc, and women choosing large sizes tend to be highly satisfied.

No plastic surgical procedure has received as much public attention, and scrutiny, as breast augmentation. Breast augmentation decreased in popularity in the early 1990s due to media attention regarding the safety of silicone gel implants, and the 1992 FDA decision to make silicone gel implants unavailable to women desiring cosmetic augmentation (but allowed back on the market in the United States in 2006). Breast augmentation has resumed its place as one of the most popular cosmetic procedures today.

The procedure is not perfect and there are problems. However, even when complications are encountered, almost all women are still satisfied with their decision to have the procedure and would do it again. Fortunately, provided there is excellent communication and trust between patient and surgeon, almost all complications can be managed successfully. Very few women decide to have their implants removed and not replaced. Some women decide to have their implants removed and a simultaneous breast lift. But even this situation is unusual. Most women of all ages will have replacement implants.

It is important for the surgeon to try his or her best to reach an acceptable outcome with implants because the alternative, “deflated” breasts, is unattractive. Excellent communication, trust, skill and patience are needed between patient and surgeon because revisions are not without risk, and several procedures may ultimately be required. Like a marriage, the patient-physician relationship is tested when there are problems.

The outcome is different from woman to woman depending on what tissue is there to start with. Human tissues are not like clay and this is the difference between a sculptor and a plastic surgeon. A plastic surgeon has to work within the limits of real materials (the nature of the skin, existing breast tissue, the shape of the chest, implants). Fortunately, there is a range of breast shapes that are aesthetically pleasing. A breast need not be perfect, and perhaps there is some advantage in not having every woman resemble a Barbie doll. Although gross asymmetry is distracting and unappealing, small differences are well-tolerated. Within general guidelines, such as appropriate nipple level on the breast mound, more upper pole fullness than lower, and a tight lower pole, various breast shapes, even slightly pendulous breasts, can be attractive.

Breast Augmentation—Usually a One-Way Ticket

Furthermore, most changes are one-way. There is simply no “back button” to get you back to where you were before. A breast augmentation creates irreversible changes by stretching the skin and breast tissue. However, the change is so pleasing that few patients would reconsider their decision. In our own survey, 98.7% of women would have the surgery again.

Alternatives to Breast Implants

Before coming to see the plastic surgeon, some women consider alternatives to surgery. Many women are understandably nervous about having surgery. It is amazing to see advertisements for creams that are supposed to enlarge the breasts, even in the 21st century. Such creams have no scientific basis for effectiveness. A “BRAVA” bra was promoted in the early 2000s as a means to enlarge the breasts about a cup size. Women would have to wear this cumbersome device for 10 hours a day for 10 weeks. The concept was that sustained vacuum pressure to the breasts would enlarge them. It never caught on because of the impracticality of wearing the device and results that were unimpressive.

Fat Injection of the Breasts

Fat injection is a more feasible alternative to breast implants. Fat injection has been a valuable addition to our armamentarium in facial rejuvenation and body contouring, such as buttock augmentation. It makes sense to consider using our own fat for breast enlargement. Women ask, “doc, can you take it from here and just move it to here?”

In the past, the plastic surgery community frowned on fat injection for breast augmentation. However, there is little doubt that it works. The problem is that several treatments may be needed. Only limited increases in volume are possible with a single treatment. It is time-consuming, and there must be sufficient donor fat tissue available, which can be scarce in thin women. Patients after breast augmentation using fat may have calcifications and excessive firmness of their breasts. Women, especially thin women, may have contour irregularities from aggressive liposuction to harvest the fat from other areas.

Fat injection cannot duplicate the results of breast implants in restoring upper pole fullness. Implants tend to hold their shape and do not deform with time the way natural breast tissue does (I often tell patients, “The worst thing about breast implants is that they are not the same as breast tissue, and the best thing about breast implants is they are not the same as breast tissue.”) Fat injection of the breasts is likely to be more expensive than a single breast augmentation procedure. Fat injection would be a more popular treatment if the results from breast augmentation using implants were not so consistently satisfactory. I have found fat injection to be a useful technique to fill in small breast defects after lumpectomies or after breast reconstruction, but not for breast augmentation.

The Desire for Larger Breasts

The desire to have fuller breasts is quite understandable in view of the importance of the breast to a woman’s sense of femininity and attractiveness. To deny this is to deny the reality of female form and sexuality. Fortunately, we live in a time when it is possible to safely enlarge breasts, so that women with small breasts need not be at a social disadvantage. With breast implants an option since the mid-1960s, it is hard to imagine a time when this was not available for women who were under-endowed. We live in a time when the “playing field” can be leveled (or perhaps “unleveled”) so breast-challenged women can compete.

Women who come to see the plastic surgeon have done so after considerable reflection. There is an element of embarrassment coming to a plastic surgery office and disrobing. Women are already dealing with some guilt about considering such a self-indulgence. Often, they are thinking about how friends and family are going to react. In the back of the mind are horror stories they’ve read or heard about. It is a wonder they work up the nerve to come in at all! And, yet they do, which shows the strength of the emotional need. In the past, women have endured truly awful treatments, such as silicone injections that led to painful lumps (“granulomas”). This was the only option for women who were born just a decade or two too early or in a country without modern standards of practice.

Contrary to popular belief, most women are not having a breast augmentation to satisfy others. Our survey (Swanson E. Prospective outcome study of 225 cases of breast augmentation. Plast Reconstr Surg. 2013;131:1158–1166) found that 89% of women are having the surgery for their own reasons, 11% for both themselves and an “other,” and less than 1% just for the “other.” And, it is not a snap decision—they have usually been thinking of it for years. On average, our patients have considered it for 5 years before having the surgery. Sometimes they have been saving for a long time, or waiting until the kids are off to college and they feel they can reward themselves. I am reassured by consistently hearing women tell me that their husbands are supportive, but in most cases, not pressuring them to do it— “He loves me whether I do it or not. But, if I want to do it, he’s all for it.” Of course, the procedure is such that both partners can enjoy the result. Usually, husbands sit quietly and a little timidly in the examining room. I have never heard a husband object to the concept of larger breasts.

What Happens to My Nipple Sensation After Breast Implants?

Surveys show that nipple sensation is important sexually to 80% of women. Of course, even if this is not the case, sensate body parts are always to be preferred. Sometimes I see women in my office who have had breast implants elsewhere who report that their only disappointment was in losing nipple feeling on one or both sides. They are usually still happy with their decision, but would be happier if they kept full nipple sensation! Sometimes nipple sensation does not get the attention it should from plastic surgeons.

A major sensory nerve supplies the nipple with feeling. This nerve is called the lateral cutaneous branch of the fourth intercostal nerve, and it comes from the side of the rib cage. It is at risk when the surgeon dissects the pocket for the breast implant. Some surgeons advocate making this pocket using cautery or a scalpel. Other surgeons, myself included, prefer to make the pocket bluntly, using our fingers. The advantage is that the nerve can often be felt and preserved intact. It might get stretched, but is unlikely to be cut. A stretched nerve will usually recover, but a cut nerve will not. This approach appears to be successful. Our survey revealed that only 2.3% of women experienced persistent nipple numbness. This rate compares with a range of 12–20% in other series. (Swanson E. Prospective outcome study of 225 cases of breast augmentation. Plast Reconstr Surg. 2013;131:1158–1166)

Common Reasons Women Choose Breast Augmentation

Of course, like other areas of cosmetic surgery, I see women who are newly single due to a marital breakup or death. They are “back on the market.” Women who are divorced, and whose bodies have suffered the effects of childbirth, want to look as attractive as possible, mainly for their own sense of confidence. They are working out, toning their bodies, and this is just one of the self-improvement items on their list.

Some women do not want to have their partner’s attention wandering. One patient told me, “I was at the racetrack with my boyfriend, and there was no denying that full-chested women caught his eye. I just don’t want to have to deal with it.”

Breast Appreciation

A breast augmentation typically improves a woman’s sense of femininity, which can boost her own feelings of sexuality. Although the priority for most women is an improved body image, almost half report a positive effect on their romantic life. Their breasts are no longer a source of feelings of inadequacy, but a source of feminine pride and enjoyment. One patient told me after her breast augmentation, “This is how a woman is supposed to look.” It is an appreciation she experiences every day, looking in the mirror, putting on clothing, shopping for clothing, wearing an evening gown, and fitting a bathing suit.

S.F., Age 29, Pharmaceutical Sales

Height: 5’7″

Weight: 124

Children: 0

Implant Placement: Submuscular

Approach: Inframammary

Implant Size: Right: 480 cc/Left: 450 cc

Implant Style: smooth, round, high-profile, saline

Preop. Bra Size: A/B

Postop. Bra Size: Small D