Underestimating Implant Volumes in Cosmetic Breast Augmentation

1 T first question to ask in determining implant size is, who makes the choice? It would seem obvious that the patient decides. However, some plastic surgeons believe it is their responsibility to educate their patients about the alleged dangers of large implants and talk them down,1 a practice I have called paternalistic.2 Mallucci and Branford1 warn of serious consequences of large breast sizes, including bottoming out and double bubbles. Like Adams,3 Mallucci’s average implant size is about 290 cc; he considers 400 cc implants, his maximum, “huge” (personal communication, March 2, 2017). Tebbetts4 also believes that implant sizes should generally be under 350 cc. On the other hand, many experienced surgeons insert implants with average volumes in the range of 390–438 cc.2,5,6 Who is correct? The second question to consider is whether large implants cause more complications. In my clinical study, there was no correlation between implant size and complications.5 Patient surveys showed a positive correlation between implant size and result ratings.2 Huang et al.6 found that women with implant volumes of 300–350 cc returned for more reoperations than those with implant volumes greater than 350 cc. The High Five system linearly relates implant volume to the base width.7 A woman with a base width of 10.5 cm receives a 200 cc implant and a woman with a 15.0 cm base width is assigned a 400 cc implant.7 The problem is implant volume is related exponentially (r3), not linearly, to diameter (Fig. 1). This geometric fact means that a woman with a base width of 15.0 cm should receive a 600 cc im-