Breast Augmentation: Lessons Learned From 56,000 Breasts

I’ve examined a lot of breasts – at least 56,000 – during my career as a plastic surgeon. How’d I get to that number? About 7,000 women have come to me for breast augmentation surgery. On average, I see each woman about four times – once before her surgery and three times afterward for post-op visits.

So, 7,000 women x 2 breasts x 4 visits = 56,000. That’s not a problem that would have been on your sixth-grade math homework.

Through the years, I’ve observed every variation in breast size and shape, in breast perkiness and nipple size, and in women’s thoughts about their figure and their surgical goals.

If I could sum up what I’ve discovered in one sentence, it would be this: You shouldn’t make assumptions about who gets breast augmentation – and why.

Don’t assume that . . . 

. . . many of my patients are exotic dancers. Only about 1 percent of my patients are exotic dancers. The other 99 percent include teachers, nurses, hairstylists, construction workers, doctors, ballroom dancers, stay-at-home moms, company executives, waitresses, fitness trainers, bartenders, cheerleaders, policewomen who want to know how soon they can put their bulletproof vests back on, and women in all branches of the military who email us from Iraq and Afghanistan to set up appointments for when they are back in the United States. This is not a complete list.

. . . breast implants are just for younger women. True, the large number of breast augmentation patients are in their 20s, women who come in because they want to feel more feminine and self-confident. “It’s pretty bad when your 13-year-old sister can already wear your bra,” one woman told me.

The second largest demographic is in their 30s. Many women in this age range come in because they liked the fullness of their breasts during pregnancy and want to recapture that look. Others have lost weight and with it their breast volume.

Women 40 and older – and even in their 60s – come in for breast augmentation surgery, too. They want to look as good on the outside as they feel on the inside. They tell me they’ve been taking care of everyone else for years and now they’re ready to do something for themselves. Many have been thinking about breast augmentation for years.

. . . women get breast implants to attract attention. “Do you want to be proportional, turn heads or stop traffic?” That’s what one of my colleagues asks a prospective breast augmentation patient to see what she has in mind. I’ve tried it. Most women tell me they want their figure to be more proportional, and they want to fit better in their sweaters, bikinis and tank tops. Some comment that they wouldn’t mind turning heads now and then. Not many want to stop traffic. Ironically, some of my patients are policewomen who literally stop traffic – but they would rather not do it with their breasts.

. . . women get breast implants to make men happy. Only two women out of 6,000 have ever told me that their partner wants them to get implants. Instead, women have consistently told me that their partners love them exactly the way they are, and they are having surgery to make themselves look and feel better. So, sorry guys. Women don’t get implants to please you. That might be an outcome, but it’s not the motivation.

. . . a woman’s breasts are the same on the right and left side. Breasts are sisters, not twins. Few women have identical breasts; the difference might be slight or more obvious. Nipple position, chest diameter, the amount of breast tissue, the location of the breast on the chest wall, and how high or low a breast hangs all contribute to the appearance. With all these variables, it is no surprise that no one has identical twins.

. . . women need much guidance from me. Women know what they want. During medical training, we are taught that we should know the answers, that we are the authority. But I have discovered that women know best. My job is to listen carefully and to determine if there is a match between their goals and what I can accomplish. I believe I am an expert at figuring that out.

What Are the Odds?

Breasts come in twos. So do shoes, socks, gloves and earrings. Many other things come imagesin threes: a three-ring circus, primary colors, the little kittens that lost their mittens, and the number of blind mice in a group.

Over the last five to 10 years, when I’ve reviewed charts in the operating room before I begin surgery, I’ve been noticing that, “Oh, look, everyone is from out of town today,” or “Everyone’s Asian today.”

My cosmetic breast surgery patients seem to come in clusters. In other words, they share some distinguishing quality. Is it a cosmic biorhythm, an unexplainable phenomenon? What are the odds?

Austrian biologist Paul Kammerer studied salamanders and toads – and coincidences. In 1919, he published a book recounting all of the coincidences he had collected. He wrote: “Coincidences aren’t coincidences at all but the result of an invisible force in nature that – like gravity, magnetism, symbiosis, and so on – favors unity, symmetry and coherence.” He called his theory the law of seriality.

I don’t know whether these patient groupings are statistically inevitable or proof of Kammerer’s law, but I do know that my staff does not arrange the surgical schedule this way. Women choose their surgery date according to their convenience; we don’t choose it for them.

Some of the coincidences can be related to the seasons. We see large numbers of teachers and students who have the same school breaks. Many other clusters aren’t seasonally related.

donuts-643277_1920Does this phenomenon occur in other settings? Does a hairstylist notice that one day all her clients are redheads; on another day everyone says, “Just cut it a little bit”? At Dunkin’ Donuts, is one day all about glazed jelly donut? Do the chocolate frosted donuts sell out on another day?

Even though my patients range in age from 18 to 67, on some days everyone is in their early 20s; on another day they’re in their 30s, on another in their 50s.

Here are some other clusters I’ve noticed: One day everybody might have children; whereas on another nobody has kids. One day all the women who live in the Philadelphia area close to my office, while on another day everyone came from out of town.

I’ve also had days where all the patients were Spanish, and others where they were all Italian or all Russian.

I’ve had days where everybody was a nurse and others where all were a stay-at-home mom.

Sometimes, the women’s choice of implant size is the common denominator: Everyone seems to be choosing bigger implants one day, while others are “smaller size day” and “average size day.” This might correlate with the stature of the patients, which is another common denominator. They might all be tall and have big frames or all be more petite.

I’ve also had days where all the patients were perkier and other days where all were droopier. And even though breasts are sisters, not twins, some days all the women are fairly symmetrical and on another day they are more noticeably uneven.

Maybe I’m observing these similarities because I’m solely performing cosmetic breast surgery, and that’s making the coincidences more statistically possible. But on a recent surgery day, when I was chatting with the OR staff and I asked them their favorite ice cream flavor, they all said mint chocolate chip.

There might just be something to this theory of seriality after all!

Some Breast Augmentation Statistics:
To measure women’s interest in breast implants across the United 
States, RealSelf.com screen-shot-2016-10-23-at-2-34-57-pmanalyzed millions of searches on its website by region for its 2011 Interest Index. (They assumed that women were doing the searching.)  Interest in breast augmentation surgery was 74% higher than the national average in Salt Lake City, followed by Fresno, Honolulu, Oklahoma City and Mobile. It might just be a cosmic phenomenon (or a lot of patient referrals) but I think Philadelphia would be on the list if they conducted the survey in 2016!

“I love my implants, but I wish I went bigger.”

“Worth it but kinda wish I went bigger.” “Love ‘em but wish I went bigger.” Breast augmentation forums, such as RealSelf.com, are filled with comments like these.

After doing thousands of breast augmentation consultations, I’ve identified four reasons that women hold back from choosing the size they really want to be. If you can avoid these traps, you’ll likely be satisfied with your choice after surgery.

Holding back based on concerns that people will “know.”
Some women don’t want others to know they had a breast augmentation, so they choose smaller implants: “I don’t want to look fake.” “I don’t want people to notice.” “I don’t want people to judge me,” they say. They need not worry.

I assure patients that most women look natural and proportional after their breast augmentation surgery and can keep it a secret if they are so inclined. Patients tell me that their most observant friends and family members are often aware that something is different. They ask questions: “Are you just back from vacation?” “New haircut?” “New outfit?” “Are you working out now?” They can’t figure out exactly what has changed.

Choosing implant size by looking at pictures taken at 3 months after surgery or earlier, instead of looking at fully settled breasts.
When post-op photos are not labeled, you don’t know how far along a woman is in the Screen Shot 2016-01-19 at 9.12.18 AMhealing process. If you are looking at online photos taken 3 months or less after surgery, consider this: The implants have not yet settled into their final position. They are pressed up high, like your breasts would be in a push-up bra. They are not fully settled until 9 months post-op, and at that point they often will look smaller than they do at 3 months. You’ll likely be disappointed if you choose your implant size from pictures that were taken three months after surgery.

In general, your breasts look smaller when you are dressed than when you are undressed. So my before and after photo book includes pictures of women 9 months after surgery both unclothed and clothed, in a bra, tank top or blouse.

Making a decision based on cup size.
Our last blog post explained that being proportional doesn’t mean wearing a C cup bra. Click here to read “Can you make me a full C cup?”

Making a decision based on Internet forums and input from friends.
You might like the 375 cc implants you saw online, but are you comparing apples to apples? The woman whose breasts you were admiring might have started out with breasts that were larger or smaller than yours, and she might be a different height and weight, too.

If you’re starting with a full B cup and that woman started with a mid-A, you won’t end up the same size when you both get 375 cc implants. You’ll be about 1-1/2 cup sizes bigger – the extra cup you started with.

Likewise, friends who have implants might weigh in on your choice: “One of my girlfriends who has implants said that the implants I selected are too large for me. She has me second-guessing myself,” a patient told me.

My advice is that after you’ve looked at pictures of women who are similar to you and your frame, and you’ve chosen the size that seems right to you, trust yourself. Go with your gut or your heart – not your head. Remember that you’re the expert for yourself.

Can you make me a full C cup?

When they come in for their breast augmentation consultation, most women tell me that they want to be a “full C cup” and they want to look proportional. They think this means they will wear a C cup bra after surgery.

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Problem #1: There is no standard bra cup-sizing system.
“C cup” can mean one thing if it’s made by Victoria’s Secret and another if it’s made by Vanity Fair. You might wear a B cup in a full-coverage bra and a C cup in a demi bra, even if the same company makes both styles. Your cup size is also affected by how tight you wear your bra band. If you wear it tighter, it will push your breasts deeper into the cup and you will need a larger cup size.

Problem #2: What looks proportional varies from person to person.
I prefer to describe proportional as a “C look” instead of a “C cup.” To achieve the C look, a 5-foot woman with a small frame might only need a B cup while a 5-foot-8-inch woman with a large frame might need a D cup.

During consultation, I show prospective patients before-and-after photographs of women who started out similar to them in height, weight, frame size and breast volume. Every photo notes the size of the implants that I used. Women look at the pictures and tell me, “too big,” “too small” or “just right.” It’s like looking through a magic mirror into the future. A woman is almost always consistent as to the number of cubic centimeters (ccs) she likes, so I know what size implant to order to give her the look she wants on her body.

Screen Shot 2016-01-19 at 9.08.28 AMWhen we are finished the process, women almost always ask, “What cup size will I be?” This is where they can get into trouble. Again, the letter doesn’t matter. It’s a cup size look. They chose a look, and it looked right to them.

Here is an example of that trouble: A 5-foot-9-inch woman with a large frame wanted to be a full C. She liked eight different pictures. They all had the C look on her body type and were all the same number of cubic centimeters (ccs). I asked her if she liked the look, and she said, “Yes.” When I told her she would probably wear a D cup, she said, “I don’t want to be a D.” She was stuck on the cup size. She decided to go smaller and was disappointed after surgery.

A woman with a small frame also wanted to be a full C. After voting on the pictures, she asked for her final cup size. I told her she would probably wear a B. “Can you show me something bigger?” she asked. She had looked at larger implants, and she didn’t like the pictures that were even a tiny bit bigger. She decided to stick with the size she liked in the pictures, and was happy with her decision.

What implant size is equal to a C cup?
Breast implants are measured in cubic centimeters (ccs), not cup size. On a woman who is completely flat-chested and has a medium-sized frame, a 450 cc implant would be equivalent to the average C-cup bra.

Bra Rules I Didn’t Know

Screen Shot 2014-11-12 at 11.12.17 PMEarlier this month, Megan Mayer wrote an article for the Huffington Post entitled “The 6 Most Basic Bra Rules You Probably Didn’t Know.” When I saw the title, I was certain I’d know all of the rules, since I’ve examined more than 6,000 women who have come to my office for cosmetic breast surgery. Turns out I scored 50 percent: #2, #4, and #5 fooled me.

Below, you’ll find Megan’s rules in orange and purple and my comments in black.

1. Bras will never be a comfortable clothing item. Their primary function is to support your breasts, so they are supposed to be firmly hugging your torso.

When my wife, Joyce, takes off her bra at night, she lets out a great big sigh. She’s always in search of a comfortable bra and never seems to find one. It makes me glad I don’t have to wear one.

Joyce is the co-author of The Dictionary of Jewish Words, where you’ll find the Yiddish word mechayah, which perfectly describes the feeling of relief she gets when she unhooks her bra at the end of the day. My mother defined mechayah as the feeling she got when she took off her girdle. It also describes how it feels to take off your stilettos.

2. Clasp those babies. To preserve your bras, be sure to CLASP them while they live in your underwear/bra drawer so they don’t get caught on other articles of clothing.

Joyce doesn’t clasp her bras; she hangs them on the doorknob of our bedroom closet for easy access, which makes sense to me. I can throw my underwear in the drawer without arranging it a certain way. This is one of the benefits of being a guy.

3. You should definitely have more than one bra. Bras are like underwear — you should have more than one pair and rotate them.

Maybe I’m an optimist, but I thought that everyone would know and abide by this rule. Megan could have eliminated it and used this one instead:

You don’t need to wear a bra. A bra will keep your breasts from sagging, but only while you are wearing it. There’s little evidence that wearing a bra delays or prevents breast droopiness or the formation of stretch marks.

4. Be aware of the gore. The center of the bra that connects the cups in front is called a gore.

It’s interesting that someone picked a word that also means bloodshed and carnage to describe this bra part. When I looked it up in the dictionary, I found out that the gore, a triangular piece of material, is used not only in making bras but also for umbrellas and sails.

5. Hand wash your bras. No dryers and no dry cleaners. Hand washing will maximize the life expectancy of your delicates.

I never thought about how you washed a bra, but if I did, I’d imagine you’d throw it into the washing machine. Happily, I can throw my underwear in the washing machine. This is another of the benefits of being a guy.

6. Your bra size is subject to change. You are most likely a different bra size at various undergarment stores. Just like clothes and shoes, bra sizes run differently.

I run into this issue every day in the office when women tell me that what cup size they want to be after surgery. The problem is that a C cup can mean one thing if it’s made by Victoria’s Secret and another if it’s made by Vanity Fair. A woman might wear a B cup in a full-coverage bra and a C cup in a demi bra, even if the same company makes both styles.

Because there is no standard cup-sizing system, I prefer to call it a C look. And to achieve a C look, a 5-foot woman with a small frame might need a B cup while a 5-foot-8-inch woman with a large frame might need a D cup.

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