Episode 44: Monday July 5

Drs. Sam Jejurikar @samjejurikar, Salvatore Pacella @sandiegoplasticsurgeon, and Sam Rhee @bergencosmetic discuss one of the MOST IMPORTANT decisions for patients undergoing breast augmentation: how to choose the RIGHT IMPLANT SIZE.

Unfortunately the most common reason for revision breast augmentation surgery is dissatisfaction with breast size. It is is extremely important to make sure patients are pleased with their breast size from the start.

If you or anyone you know is considering breast augmentaion, this episode is a MUST WATCH!

#podcast #plasticsurgery #cosmeticsurgery #boardcertified #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bestplasticsurgeon #implants #breastimplants #breastaugmentation #breastaug #boobjob #gummybearimplants

S02E15 Show 44 - Choosing the Right Breast Implant Size

Dr. Salvatore Pacella: [00:00:00] Welcome everybody. We're back. This is three plastic surgeons and a microphone. Dr. Sal Pacella from San Diego, California @sandiegoplasticsurgeon is my Instagram handle. We have Dr. Sam Rhee here from Paramus. New Jersey. His Instagram handle is @bergencosmetic, and we've got Dr. Sam from Dallas, Dr. Sam Jejurikar and his Instagram handle is I always mess this up. It's @samjejurikar or at dr. Samson. At Sam Jejurikar. Alrighty. 
Welcome back everybody. I've been on hiatus for a couple of weeks. Had a little bit of a knee injury I was recovering from, but I'm back at least to, to speak on the mic.
Here we go. And today's topic, we're going to be talking about breast implant sizing, one of our favorite subjects. But prior to that, I'm going to hand it over to these guys to do a little disclaimer. 
Dr. Sam Jejurikar: [00:00:54] Yeah. So we want to remind everyone that this show is not a substitute for professional medical advice, diagnosis, or treatment.
The show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified health provider. With any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something you saw on this show.
And with that, I'm going to turn it over to Dr. Sam Rhee to lead this discussion. 
Dr. Sam Rhee: [00:01:25] Thanks Sam. It's good to see you back Sal hope your recovery has been going. Today, we're going to be talking about breast implant sizing. So this is one of those things that we talk to every one of our breast dog patients about.
And it's probably one of the most important choices patients make when they opt to have breast augmentation. The number one reason for surgical revision after breast augmentation is changing your breast implant size. And so if you can get it right the first time that is. Really important breast augmentation is one of the most common procedures that we do as plastic surgeons with cosmetic surgery.
Last year it was a 193,000 times. Ah, it was performed over a hundred and three, three hundred ninety 3000 times in 20, 20 down a little bit from 2019, probably due to COVID. I think all cosmetic procedures were down a little bit. But it's still like one of the top two or three. Cosmetic procedures that we do.
And your surgeon and how they help you decide what size you want to be is incredibly important. What are some of the intro introductory types of information or things that you say to your patients when they come to you and they ask. Dr. Pacella in San Diego or Dr. Jejurikar in Dallas, what size should I be?
Dr. Salvatore Pacella: [00:02:42] Guys, I, I'm confused. I thought it's, this topic is very easy, right? Because. There's, aren't there like just three sizes, right? A, B and C. And no one wants to be an a right. So B, C and D. Right, it's that simple. So the reason we make the reasonably joke about this is because obviously, the language that we use as plastic surgeons to describe size and describe shape, it doesn't really translate into, the patient world.
Because when you go to shop for a bra at Victoria secret, It's B, C or D. Right. And so many patients come in and we talk about sizing. What size would you like to be? I'd like to be a large C and so that the key to understand here, I think for patients and surgeons alike is it's C is a very broad category.
It's small, what I liken it to is small, medium, large. And so if you go to a tailor, you're going to get fit, you're going to get sized, you're going to get your inseam, et cetera. You may be a 36 regular or a 44 short, so there many different aspects of sizing than just the BCD.
Dr. Sam Jejurikar: [00:03:47] And a follow up on that as well. When I first started in practice and maybe this is true with you guys as well. I thought I was great at figuring out cup sizes. I thought I could look at something and say, that's a C cup. That's a D cup. And the further the more of this I do, the less confident I am in cup sizes.
And I think one of the biggest things is I think years. Victoria's secret was probably the first one, but they realized from their brilliant marketing people that if they make cup sizes seem larger than they actually are. So they use some degree of cup inflation, if you will, they sell more broads. So there's a lack of consistency amongst stores.
So when patients want to talk in terms of cup sizes, I very quickly try to return it to a, more of a dimensional analysis. And following up on Sam's initial question, what are the things that we always say. Luckily I think the trend is switching, but up until three or four years ago, it seemed as though people always came in with this notion that I need to go a little bit bigger than I think that that I want because all my friends tell me I'm going to regret it if I don't go larger.
But I think with some of the celebrities that Sam was talking about, some of the just the general increasing awareness that's happening in society. People realize now, I need to pick the size that I think matches my body is not just about going bigger. And so what we try to do, and I know we're going to talk about this more is bringing it back more to their measurements, their goals, and not just focus on cup sizes.
Dr. Sam Rhee: [00:05:10] And, we know that over time people's image of their body changes and, we've seen. And we all do, over time, what we think our ideal body shape is can change from twenties to thirties, to forties. And last month there was a highly prominent feature in people magazine with Paula Abdul.
Who's now 58. She underwent breast reveal. Surgery to remove implants that she felt were a little bit too big for her body. She felt they were weighing down her chest. And she said as years go by gravity happens. I felt they were too big for my frame. I wanted to she wanted to change so just remember that.
When you do decide what your implant size is going to be. You're deciding for yourself now and accept the fact that maybe in the future, things may change, but you shouldn't go, as Sam said bigger, just because you think you in the future, you're going to regret that you went bigger, you choose what you think you should be right now.
And typically that'll make you the most happy. I want to go off on what you said about cup size, 34 C is such a meaningless number, as you said. And yeah, when I see patients, they have padded bras, they have underwire bras, all these bras have so many different helps for patients that it really doesn't matter.
I Much when I even look at the bra to understand what it is that a patient wants. As you said, Sam Sal, small, medium, large that's about all I can take off from what patients say about bras size. Let's talk a little bit. Go ahead. 
Dr. Salvatore Pacella: [00:06:41] I was going to say two and then, I oftentimes see patients that go in the opposite direction other than just C or D they come in and they say I absolutely, want.
3 75 high profile this manufacturer. And and a lot of that comes from just doing internet searches, seeing patients with different types of implants and, oftentimes what I see. Is patients pick an implant based on what it looks like in that person, in that photograph. And so I think the key to understand for patients and doctors alike is not every implant looks the same in every patient, there are so many characteristics. In patient evaluation that we keep, that we take into account the skin thickness, the breast width the coverage of the implant existing breast size.
So it is a fairly complex process, but the key comes back to the patient's diet, the patient's physical exam and measurement. 
Dr. Sam Rhee: [00:07:36] Absolutely. So let's talk a little bit about physical aspects and how they impact what patients. Might want, so you're absolutely right. I have the same thing. A lot of patients will come in and they said, I want a three 50 high-profile because my friend Katie has a three 50 high-profile they look awesome on her, but obviously her friend has completely different physical dimensions.
So w when you look at a patient's height and weight and their. Sort of chest dimension. What are you looking for when you, and what do you talk to a patient when you see them about that? 
Dr. Sam Jejurikar: [00:08:12] I I'll lead this. I know we're all going to have a lot to add to this. It's a complicated thing.
I think, the first thing is you try to find out what's your goals. Do you want to look natural? Do you want people to know you have breast implants, probably get a general census to what their goals are. Before before making any implant decisions, then the physical exam is huge. The things that we've already discussed measurement.
So what are we measuring? We're measuring the width of the chair. We're measuring the width of the breasts. You want to have an implant for lack of a better way to put it. That actually fits within the existing dimensions of the breaths. If you pick an implant that's or too narrow, it's going to sit really low on the breast and you're not going to see me do that.
Upper pole fullness. If you pick one, that's really wide, it's going to go on the armpit. It's going to sit really high. It's going to look fake and it's probably going to be more likely to stress the tissue out. You look at the overall degree of ptosis and for patients out there, ptosis is the amount of sag that you get of the nipple, when you have a completely flat chest, a girl who has very little breast tissue, you're likely to have almost no ptosis.
If you have a mom of three, that's breastfed, all three kids, you're likely to have a lot of sagginess at the skin envelope and in those sorts of situation, You need to, you need the implant a lot more to recruit some soft tissue. Sometimes you have to do some additional procedures on the skin, like a breast lift, for instance you look at whether or not they have implants.
You, and then finally, like Sal had mentioned, which is so true when they come in and they say, I want a high-profile implant because it's gonna make me look. More look like I have more proponents, but I don't want to be too big. You have to spend a lot of time explaining to people what profiles mean.
And from a dimensional standpoint, how that's going to affect their work. I'll turn it over to you guys because I know I could talk forever as you can. And I don't want to be the only one doing that. 
Dr. Salvatore Pacella: [00:09:49] Yeah. I would say that I echo everything you said. But for me, the single most important attributes of their physical exam is the breast width. On average most women are anywhere from say nine to 12, 13 centimeters sometimes if you're wide or large. And so it's important for me to understand that number because it's as Dr. Jura Carson. If you have an implant, that's too wide.
It made me in a uni boob situation too. And so we just got to nail the footplate of the breast correctly, and that will usually kind of range us within the certain profiles. And if someone wants a little bit more of an augmented look, that's going to be more on the high profile side. If someone wants a little bit more of a natural look on the moderate side, the implants that are on the absolute extreme profile.
What are called the moderate classic, which are very thin implants. I use those very rarely and implants that are super round or larger high profile. I also use those rarely. Those are sometimes mostly used in a mastectomy situation, if someone wants a really large double D breasts, then that's a decent implant to use.
Dr. Sam Rhee: [00:10:55] Yeah, I think I could, I agree more with both of you guys. So especially Sam, a lot of personal considerations about the patient is very important. Like you said what do they want a natural look, a slightly augmented look or a very obviously augmented look, they, I have patients who will come in wanting any range of those looks and it's up to us to help.
Achieve that that upper pole fullness where it's full on the upper part of the chest is something to definitely discuss with patients. The other thing is lifestyle, if these patients are extremely active they may not necessarily anticipate what a very large implant might do, or at least we have to remind them.
The other thing I wanted to mention is I have a lot of patients who say, I want a lot of cleavage where, the implants are very close near each other in the middle of the chest. And it really depends to some degree on their anatomy as Sam or Sal said, it's that base diameter of the breast and where it's located.
If they have. If you, if they, if their breasts are wide apart to begin with, you have to achieve a very wide breast implant, like a wide base diameter in order to try to get there. But that also means you're going to go wide laterally too, on the side, which they may or may not want in order to make sure that the implant is centered appropriately on the chest as well.
Dr. Sam Jejurikar: [00:12:21] So my question for you, two gentlemen, cause this is something I. Kind of evolved in my approach over, over the years is I think we, the way we're talking, we know a lot about this. We probably know more than the patients do by, by a long amount in terms of how to pick an implant, but clearly they have strong opinions.
So how do you communicate with the patient? What your goals are for them? How much say do you let them have in choosing the final implant? Do they choose the final implant and how do you make them comfortable with that? How do you show them? Do you put implants in a bra? Do you use off the shelf?
Sizers? Do you have them put rice in a bag? Like how do you help the patient visualize what the results are going to be based on your record? 
Dr. Salvatore Pacella: [00:13:02] Yeah so I have so the way I do implant sizing is very strategic. So for example many providers I know in the community, they see patients for an initial consultation.
They do the sizing at that time. And that way a patient comes out of the office saying, oh, okay, I'm going to see doctor X and he's going to give me a 3 75 and this is the cost. And so I don't necessarily do sizing at the initial implant appointment because of the patient hasn't even decided on surgery yet.
So we'll have them come back for another visit for their pre-op appointment. And that's when they do the sizing. And I say I want you to do some homework for me prior to coming back. I said, what I want you to do is not necessarily look at the plastic surgery websites, but I want you to pick out a magazine, go online, go on Instagram.
I want you to show me, bring in next time, some photographs of breasts that you look like, that you want to look like in clothes, in bikini's in bras. Okay. And bring that in and we'll talk about everything. Including profile, shape, size, et cetera. I found that just really narrows down our search really nicely because, w that's lost in translation CD 3 75, it just doesn't make a lot of sense.
So from those photographs, a picture's worth a thousand words I can easily say, oh clearly you're looking for a higher profile implant. Let's be in the high profile column. Let's check your breasts with. Let's look at a range of implants and we usually together pick about a range of three implants, and I'll bring those into the operating room.
You sizers and then decide personally myself. So I cannot, as your surgeon guarantee you, you're absolutely going to get X size implant. 
Dr. Sam Jejurikar: [00:14:51] That's just how I do it. What about you, Sam? 
Dr. Sam Rhee: [00:14:53] I've done it a couple of different ways. I really do. I like Sal's photo. I do that a lot. I think that's super helpful in telling me most importantly, how much upper pole fullness they want, do they want it to be really obvious or not?
And that you can tell a lot just from the photos that they sh that they show I know a lot of surgeons have used the plastic bags of rice or water, and I've used that before as well. And I think that can be helpful. I took an allergen CLA like seminar, like maybe two or three years ago and they, and this guy does, I forget his name, but he did a ton, all he did was breast augs and he was a huge proponent of the silicone sizers, the. The ones that are preformed that you can put yeah. That you can get from the manufacturer that you can put into a bra. So we just tell patients to bring a bra and not, just a regular bra and we work on sizing with them with that.
And that has been. Incredibly helpful for a couple of reasons. One, it helps them understand the weight to us, but to a certain degree it helps them see what they might feel like with it. As opposed to it just gives them a little bit of a physical sense. There are some drawbacks, I think.
The sizers is under estimate a little bit, the actual volume of the implant. So usually I'll talk to the patient and get their leanings and, adjust the final implant volume guests according to what they choose based on the sizers. And then I do what Sal does. I have a usually a range of a couple of different sizes that I bring into the, or interoperatively figure out with the temporary sizers what's if that achieves what the patient wants, and then that's what I will go.
Ultimately, that has helped me achieve a very high degree of getting what the patient's goals are, but it really just does depend. And I know you use a different method, which I'm really excited to hear about, because I think that's also a good way of doing it. 
Dr. Sam Jejurikar: [00:16:50] Yeah, I have I have evolved in the way that I do things.
Just because I've gotten a bunch of much like you guys I've done. I do a lot of breast augmentation in my practice and being somewhat cynical by nature. I think 90% of patients that come in and tell me they want to be natural. Maybe 50% actually mean that they want to be natural. And so the communication sometimes was difficult to get what people wanted.
We would largely use the preform silicone sizers, like you had discussed. I actually had every breast implant made by Allegan in my in my office. So we would, I would do measurements. I would give an assistant arrange. We would spend time with a sizing bra to try to put the implants and get a sense as to what they might look like.
But then, once they had picked an implant, then we would have to do a lot of manipulation of the actual implant during surgery to get them that size, which sometimes it leads to people being upset. About five years ago I switched a lot to 3d imaging and during the pandemic, the way my, my patient flow really the way I did breast stock consults really changed quite a bit.
So I'm gonna pull up this 3d imaging software, if I can. And show it to you guys. Can you, hopefully you guys can see this program here. So the way this image was created for this. This was a patient who initially I did a consult on and I never even met them. They were at home, they took three pictures on their cell phone.
They'd have to do one measurement. They have to measure the distance between their nipple. And typically we don't have the, the bathing suits off on here, but we're doing it for the sake of demonstration. So based off of that, it creates this model on your left, and you can see the patient from a variety of views.
And again, this is all generated by the patient using their cell phones. And this is a program from called Chrysalis, which I've used for about five years and the technology is quite good. So then it creates dimensions and that actually tells me what the diameter of the patient's breast is. It doesn't allow me to adequately, we assess her soft tissue, which is really important, but it's create dimensions.
And then we do it a lot, like the way you are when you go to an eye doctor, I might start off with an implant that I know is going to fit their chest. And be in the middle in terms of natural and they'll like it, they won't like it. We'll try to change the size. We'll try to change the profile, which basically is how much the the implant will stick out and then we'll see a variety of images.
So what I've done on this one is just show a really large implant. To get a sense as to how that might look on their body and on the right, one of these high profile implants. And, I might tell this patient, if we put implants in this large, I want you to see it's going to make you look like you've gained a lot of weight, even though you haven't, it's going to obviously be heavy.
It's going to drop over time, and then I'll show them the one in the middle, which I think fits their body much more appropriately and give them an idea. But it's helpful. Dissuade people from picking implants that don't fit their body very well. What I typically will do is I do the sizing on the phone first appointment, but then I'll see them for a preoperative appointment, which is reasonably quick to confirm the sizing that we did at the preoperative appointment.
And a lot of times we'll make some modifications. I typically only use sizers these days, if there's asymmetry in the cases, which is very common. So I'll use them for cases with asymmetry but most of the time I'm pretty committed to them. Going in there. And so this has changed. This has changed the way that I've, that I have done my consults tremendously and I'm a big advocate for it.
It's actually sped up the consultations as well. I used to find that breast augmentation consults were very time-consuming and now the typical breast augmentation consult, the first one takes about 30 days. The followup one takes about 10 to 15 minutes and and we have very good communication and people feel a lot more comfortable.
It even has this view, which every patient evaluates their results on which no plastic surgeon can ever see, but every patient looks down and assesses the results that way. So I've, I have found it to be very helpful. 
Dr. Sam Rhee: [00:20:29] I really like it in the sense that especially with the pandemic and with more and more video consultation, the fact that I did not know that you could just have them send you pictures and then have that and use them for that 3d imaging software. That's pretty cool. I never thought I would actually be doing surgery on patients that I would not actually see until the day of surgery, but I have done that. I am doing that more now than I ever have, especially with patients from we're coming from a distance.
And, particularly in that regard, that would be. Super helpful. In terms of communication you're right. It is time-consuming with the sizers I haven't bit on the 3d imaging yet, but it's something I would consider. Ultimately it's really about I don't care how a plastic surgeon eventually gets to.
The decision making process with the patient, as long as they truly understand what it is that the patient wants and they can achieve it. It doesn't matter, what method it is, as long as they can get to that point. Clearly this is a pretty cool way of doing it though. I like it. 
Dr. Sam Jejurikar: [00:21:32] It's certainly nothing is perfect, including 3d imaging software and and much like we read a disclaimer before we do this podcast.
There is a disclaimer, that's broadly across the bottom of this, that this is, there are limitations of it, but I will tell you that over the five years that I've now used this program, it's gotten really good and really accurate. And they've now about a year and a half, two years ago incorporated an AI machine learning algorithm to it so that they literally take these horrible cellphone pictures that patients will take.
And generate these incredible models that are quite good. And it's, the patients don't even send me the pictures. They upload them directly to the app and they do this one measurement, which they have to do in centimeters, which for some reason, confused as many people. And so sometimes you have to do some tweaking on that end, but they do that's one measurement and it's pretty accurate from a sizing standpoint.
But again, it's really important, even if that preoperative appointment is on the day of. Which is oftentimes the case for out of town patients, because a lot of my patients just like you guys come from a fair distance, you really need to confirm the measurements before you operate on that patient, because there will be some time changes that you make.
But it's very easy to double-check it 
Dr. Sam Rhee: [00:22:37] I think this is super helpful, especially for patients who want to go super large and maybe they don't have. The tissue thickness that you know, would really lend themselves to an optimal result or. Does this take into account ptosis or sagging as well? If they have really saggy, are you going to be able to see that?
Yeah. 
Dr. Sam Jejurikar: [00:22:55] Yeah. And you can fact simulate a breast lift. Unfortunately, I can't do that while they're wearing a bra. And I'm happy to show that to you offline and we don't have to be concerned about social media standards, but yeah, you can simulate breast lifts, different different decisions with it.
Show them kind of what they can expect with that as well. It's good. It's not, I find it to be very helpful in the realm of breast surgery for straight augmentation and augmentation with lift. I do not find it to be that helpful for breast lift alone or for fat grafting cases though. It's getting there.
They're working on that too.
Dr. Sam Rhee: [00:23:23] Ahead. Go ahead. I was just going to say, I think. It's funny. I have seen patients who have come in for revisions, and I think the biggest issue has been surgeons imposing their opinions, pretty heavily on patients. Almost telling patients. And I think maybe this is something that happened more, say a decade ago or longer basically telling patients what size they ought to be.
I even had a patient recently who came in, who had a breast aug done the on the day of surgery. I couldn't even, I didn't know if this was true or not. She said the surgeon did not have the size she wanted available, but told her that she'd be better off going up, a hundred CCS. And she agreed and she said she regretted it now again, This is from the patient.
And I did not talk to the surgeon themselves about the situation, but, clearly I have encountered patients who felt like they were pushed into a particular size or not based on technical considerations. Like we always want to let patients know, from the, the tissue super thin, you're going to have a lot of rippling. You have other issues sagging just purely on an aesthetic basis, whether or not it looked.
Dr. Salvatore Pacella: [00:24:39] I got good choices, gents. I think I think the key to this discussion is many different ways to get to the same place whatever works for you works. The imaging technology is very nice and it clearly is improving. Years ago we used to have to purchase this big, massive camera machine for patients to come in.
And it w it was a huge, a huge outlay of resources. So it's glad to see this is getting. 
Dr. Sam Jejurikar: [00:25:05] Yeah, I, I think I'm piggybacking on what both w what you were saying, what particular with Sam was saying about surgeons and posting their well 3d imaging allows patients to make informed choices.
It doesn't preclude us from giving very strong medical advice. I have with 3d imaging, I've been able to talk before into smaller implants than I used to do before, because they can actually see how it matches their body a lot better. And ultimately a surgeons. Yeah. All things being equal.
We would love to err on the side of smaller implants than bigger implants because the long-term repercussions for a patient's body are going to be substantially less. So I've, I have found it effective as a communication.
Dr. Sam Rhee: [00:25:39] Coming from a plastic surgeon in Dallas, Texas. That's a very enlightened way of thinking. 
Dr. Sam Jejurikar: [00:25:43] Don't don't believe every stereotype you hear, not everything is bigger. In fact,
Dr. Salvatore Pacella: [00:25:53] All right, gents, I think we had a great discussion today. I want to thank both of you for joining today and any final parting thoughts, gents? 
Dr. Sam Jejurikar: [00:26:01] I think this has been enlightening and it's always great to pick your guys' brains on these topics. 
Dr. Salvatore Pacella: [00:26:07] All right, guys. We'll signing off. Have a good Sunday.