How Big Is Too Big? What to Know About Breast Implant Sizing with Dr. Jessica Walker

Dr. Jason Hall:

0:00

All right, breast implants. How big is too big? That's the question. Both Dr. Walker and I do lots of breast surgery, and the subject of sizing comes up is talked about in every single consultation. Today, we're going to sit and talk about breast implants. Breast implant sizes, how big is too big, and what could happen if we go too big. So, welcome to the Trillium Show. My name is Dr. Jason Hall, board-certified plastic surgeon here in Knoxville, Tennessee. And today I am joined again by the lovely and talented Dr. Jessica Walker, and we are going to talk about breast implant sizing, specifically big implants. How big is too big, and more importantly, what can happen with implants that are too large, and how we can go about fixing those. So, Dr. Walker, welcome back to the show.

Dr. Jessica Walker:

0:58

Yeah, thank you for having me.

Dr. Jason Hall:

0:59

So, it's

Dr. Jessica Walker:

1:00

gonna be a good topic,

Dr. Jason Hall:

1:01

it is. It's something that comes up all the time. So I guess the first question is, what makes a breast implant too big for a given patient?

Dr. Jessica Walker:

1:13

Yeah, so you know, we talk about sizing all the time, and it really depends what your goals are. Okay, and we talk about, you know, here in Knoxville, or at least at our practice, I think a lot of the majority of the patients that I see are people who want to be proportionate, they're deflated from weight loss or having children and breastfeeding, and they just want to be proportionate, feel feminine again, nothing too crazy, and but you get those patients here and there that you're like, okay, maybe we need to talk about what's going to happen down the road, and it all depends on the patient, you know, like, we all, you know, we say taller patients or bigger patients can carry a bigger implant, you have a bigger frame, you need a bigger implant to help fill out and get to that goal photo, but at what point is it, is something going to be too big on, and it's going to be individualized for every person, you know, there could be, you know, a small, petite, 110 pound girl where an 800 cc implant is massive, but you have somebody who is six two, they're more like 160 170 pounds, and that 700 cc implant looks great on them. So, how big is too big? It's patient dependent.

Dr. Jason Hall:

2:17

I agree. I think that this is a good time to kind of talk about how to choose implant sizes in general. We

Dr. Jessica Walker:

2:26

just talked about this in the office. We talk

Dr. Jason Hall:

2:28

about the office every single day, so and not just together, but with every patient that comes through, and we talk about breast implants. So, how do you size a patient for breast implants. How's that done? Is it just random, or is there.. is there some science behind it?

Dr. Jessica Walker:

2:46

Yeah, so you know, and I think we do this both a little bit differently, depending on the patient, what they're coming in for surgically. So, you know, for me, I always start my consult off with, you know, what brings you to see me, and you know, even though my nurse has kind of given me a heads up on things, I always want to hear from the patient what their goals are, because sometimes they tell me things a little bit differently, and we do ask about cup size, but to me cup size is arbitrary, as you guys know, and as I know, because I wear bras. No matter where you shop, you're going to have a different bra size. Victoria's Secret always upsizes you, that's their marketing, just it's going to be a different bra size, but you telling me what cup size you are lets me know that you think what you are is a B cup, even if it's not a B cup. So that way, if you say, "Okay, I want to be a D cup, I know you want to go up two cup sizes, depend, no matter what, what you are. So cup size helps me, just kind of gives me what you, the perception of what you think your breasts are. But the best thing for me that I like to use are number one, measurements, two, height and weight, and then three goal photos. That's the best thing that you can do for me is goal photos, and ideally goal photos are from a professional, like another plastic surgeon. My website, ideally, is the best, obviously. And then you know other plastic surgeons' websites, where it's topless photos, so they're not being pushed up with a bra or pushed up with a swimsuit, but even the pushed-up photos, I can generally kind of tell, and then goal photos. Also, you want to try and find somebody who's of similar height, similar frame, similar age, and somebody like, if you need it, if you need a lift, you want to find somebody who has had a lift. If you don't need to let you know, you want to find somebody who's of similar quality to you. You know what you're, what we can achieve based on what you look like. So, for me, goal photos is the best thing, and then height and weight is kind of plays into it, and then measurements, and for you, I think you use a little bit more technology,

Dr. Jason Hall:

4:29

yeah, sometimes for primary breast augmentation, so you've never had implants before, and we're all we're doing is increasing size, improving shape. I do use the imaging Vectra imaging, which I found to be pretty good, not in terms of choosing an implant size necessarily, but in making sure that you the past. Patient who is, who wants an augmentation, and me, the surgeon, who's trying to get you to that goal, that our goals align, that your idea of C cup and fullness is the same that I'm thinking after I examine you, so what the computer says in terms of implant size is sometimes close, sometimes not, but I use those photos, the computer-generated photos, to give me an idea, make it, make a

Dr. Jessica Walker:

5:33

goal photo

Dr. Jason Hall:

5:33

that we're making, that we're speaking the same language, yeah, and then what I typically will use as, as my measurement is the width of your chest, how wide you are from, you know, the kind of the edge of your one edge of your breast to the next, because the primary driver, and this is like back to high school geometry, the primary driver of volume is diameter or radius, really, but the diameter of your chest, how wide your chest is, is going to tell us where we need to start in terms of implant sizing, and then using those measurements and a goal, that's when we pick projection, we pick how far that implant sticks out from your chest, whether it's a flat implant, whether it's an implant that's really, that is really proud, sticks up really far.

Dr. Jessica Walker:

6:26

Yes,

Dr. Jason Hall:

6:27

that's where that determination is made in my practice. And then we, then that also, then we get into, you know, is it over the muscle, under the muscle, we need a little more right to show some upper pole, if it's under the muscle, then we are over the muscle. So there's, there's some art in there, there's some science in there, and it really is kind of, kind of like yours is a marriage between what our goal is and the science, the measurements behind

Dr. Jessica Walker:

6:52

it, right, exactly, and you know, in some patients who, you know, they come in, and I do get some patients who come in, they're like, I want a 360 and I'm like, well, why do you want that, and they're like, because that's what this person has, this person has, this person has, and I'm like, okay, well, a 360 on you is not going to look like what it looks like on them, it's going to look different on everyone, so you know, the best consultation is one where you and the surgeon, your goals are aligned to get you to that goal photo, doesn't matter what size the implant is, as long as you can describe to me, what you want, we have goals to achieve, and if it's a 360 it is. If it's a 425 it is. And I, again, same thing with cup size, don't get fixated on numbers or cup size. I want to see what the goals are, and let me get you there.

Dr. Jason Hall:

7:35

Yeah, I like to, I kind of use the analogy of going to a restaurant, is you know, you go to a restaurant that you like, you order a filet medium rare. You're not telling the cook that you want it cooked over a wood fire versus on a skillet, and then finish it in the oven. You're not telling them how to season your steak. You know, you know what you want, and you let the chef kind of make all the little decisions to get you from hungry to a tasty steak,

Dr. Jessica Walker:

8:07

yes.

Dr. Jason Hall:

8:08

So it's, it's, there's, there's, and that's where the trust comes in, right? And building that relationship in a consultation that you know you're confident that you can achieve their goal, and they're confident in you as the surgeon that you can get them there, right, that you have the same goals in mind.

Dr. Jessica Walker:

8:26

Yes, and then those goals come into play when it's, are your goals a little unrealistic, or is it too big?

Dr. Jason Hall:

8:33

Yeah,

Dr. Jessica Walker:

8:34

and that's kind of where we wanted to gear this toy. So,

Dr. Jason Hall:

8:36

so then what happens when we go too big, what are problems if, if our, you know, we're we're kind of pushing the envelope in terms of size and what makes an implant too big for a given patient,

Dr. Jessica Walker:

8:55

right? Well, I think all the things we talked about kind of play into what's going to make something too big for someone is, you know, measurements, height, weight, things like that, but the complications that come with a big implant are big complications, not really complications, or more like, what problems down the road are we going to have to fix, you know, a breast augmentation, and I say this, I wish it was a one and done situation, but majority of women, if you have an implant, you are likely going to have a second surgery at some point in your life, whether it's to go bigger, to go smaller, you want them out, you need a lift now, something's changed, there's an issue with the implant itself, and when you have a bigger implant, you know, studies show increased risk of neck and back, kind of same thing, of like somebody who needs a breast reduction, somebody with large breasts, neck and back pain rashes, you're stretching the skin, you know. And then when we go to do the revision, we can be limited in our options and what we can do for you. So it's tough, but I mean, there's times where I have told patients that I don't think that I can achieve the goal that they want, because, you know, I don't want. To give them these problems down the road,

Dr. Jason Hall:

10:02

what one of the things that I think patients who are, who are interested in breast augmentation or revision surgery, may not understand as well as we do as the surgeon, is what happens to the skin and the breast tissue with a big implant over time. What are some of those things that you run into and practice?

Dr. Jessica Walker:

10:27

Well, a lot of people don't realize if you have a very large implant, it is going to put some pressure on your natural breast tissue, and it can thin your natural tissue out, so down the road you won't have as much breast tissue as you did when you were younger and first got the implants. Skin is elastic, it's going to stretch, and as you age, unfortunately, in your early 30s, your collagen peaks. I wish it was longer, but it doesn't. And collagen is what keeps your skin nice and youthful tight and elastic, and as you age, you're going to lose that collagen, and then you have a heavy implant in there, so even say we take the implants out, your skin's not going to retract like it would do when you're like 20 years old, so you're going to be limited in what you have option wise with your skin as well, because you're just having your skin ages as well, not just the implant and things like that, but your body is going to change with that implant, and too large of an implant is can definitely limit your options.

Dr. Jason Hall:

11:22

Why does thin skin and thin breast tissue in when we're talking about revisions? Why does that matter?

Dr. Jessica Walker:

11:32

You know, when we're stretching out the tissue, the one of the biggest things in breast surgery that we're always concerned about is blood supply, and when we do lifts or reductions, we to maintain blood supply to the areola and the nipple, mainly we, it's left on a pedicle, meaning there's an area of the breast that we do not cut, and there's superior pedicles, meaning we don't cut up here, there's inferior pedicles, so we're taking tissue from above but not cutting below, so that's maintaining the blood supply to the nipple, but when you have a big implant in there, and stretching everything out. It's going to do the same thing to those blood vessels, so it can decrease your blood supply down the road and cause wound healing issues, higher rates of nipple necrosis, or the nipple not surviving surgery, which unfortunately there's not tons of great fixes for if the nipple does not survive. So it can be very detrimental for wound healing.

Dr. Jason Hall:

12:23

Yeah, and in with revision surgery, especially in those patients who have big implants, they're the architecture of their breast gets destroyed, the breast crease gets destroyed and moved way down onto the abdomen, the border of the breast, kind of in the armpit, gets destroyed, and you have an implant that sits under your arm when you lay down, and those anatomic boundaries of the breast can be really hard to recreate.

Dr. Jessica Walker:

12:55

Yes,

Dr. Jason Hall:

12:56

and then you add the the added x factor of blood supply onto all of that, because we're, you know, when we're doing revision surgery with a lift, especially, you kind of think about that as like breast origami, is we're moving things around, the scars on the outside look the same no matter what we do,

Dr. Jessica Walker:

13:19

right,

Dr. Jason Hall:

13:20

but it's what happens on the inside that really makes or breaks that operation, and when you're dealing with skin that's really, really thin and stretched out, and a blood supply that's really, really thin and stretched out, it makes those, especially bigger movements, much riskier.

Dr. Jessica Walker:

13:36

Yes,

Dr. Jason Hall:

13:38

and it can cause a lot of problems if you, when you see patients with big implants that want revisions. How do you talk to them about those things?

Dr. Jessica Walker:

13:49

Well, I'm pretty blunt, so you know I don't like to sugarcoat things. I tell them there's, you know, if I will do the surgery, sometimes there's times where I do tell patients no, it's just it's not something that I think I can improve on, or their problem is something that you know I always want to fix everything, but there's certain things that we do say no to in plastic surgery, so you may be limiting your options in that, that you may not find somebody who can help you. People with too big of implants, we talk about all those things that we just mentioned, you know, you're very limited in options. People who have implants who want them completely out, that may not even be an option, because everything's been so stretched that when they, when we take it out, we do a lift, or whatever we need to do to tighten the skin up, they're left with literally nothing, and the option is to still have an implant but significantly downsize. And so I'm always, when patients have complications, issues, problems with the breast, my answer is usually to go smaller too, and that's been coming up recently. I've had a lot of patients who want to go bigger to fix problems, and that's not the answer ever, really. I don't think to go bigger, but when I see these patients. I'm very straightforward, and that they're limited. It may not be feasible. It may take multiple surgeries. It may take more power in the or like mesh, internal sutures, things like that. It's a more painful recovery. It may need drains, which I don't traditionally use drains, and a lot of patients don't like drains, but it's hard when they get these first things done, and they may not have been educated up front about, oh, in 10 years from now, what's going to happen, or what are going to be my options, and now, and it's a lot more money to do a lot of these cases as well for patients, because it's a lot more work, and can require multiple surgeries. Yeah,

Dr. Jason Hall:

15:36

they're much more complicated. Those revision surgeries are much more complicated. One of the things that we see, I know you see it in the office, I see it in the office, is I think one of the big drivers of women who get implants that are probably too large for what they need is women who want to avoid a lift by using a bigger implant. Talk a little bit about that.

Dr. Jessica Walker:

16:06

The answer is no. If you need a lift, you need a lift. Going bigger is not the answer, and I'm pretty strong on that. If you need a lift, you need a lift, because oftentimes what I see is patients who then come to me who were not with me initially, or they saw me and I said no, you need a lift, and then they went somewhere and just got a bigger implant, is they still need a lift, and now they're bigger than they wanted to be, and so now it makes the second surgery more complicated. If you need a lift, you need a lift, and I've even had patients say, "Well, they said I need a lift, and then on the table, once they put bigger implants in, they said it, they just going to do the implants, and they didn't need to do the lift, and like, if you need a lift before, based on your measurements, your anatomy, a bigger implant is not going to fix that, and you may not be happy with the size, so I'm pretty, that's a pretty, pretty strong on that one.

Dr. Jason Hall:

16:49

So you're not using bigger, bigger implants to avoid a lift? No, that's not okay. Yeah, yeah, I agree with that. I think that probably, at least in in my practice, we end up seeing a lot of those patients that are mid 30s, early 40s, and want more volume that they've lost through weight loss or pregnancy or just age-related changes, and end up getting an implant that is too big, and now we're stuck with still needing lift, but we've got all of the tissue problems that come with having a large implant with poor quality tissue that's been stretched out, and you're having to deal with all of that, not to mention the fact that the patient comes in already unhappy that they didn't get what they want the first time,

Dr. Jessica Walker:

17:46

and I think we're seeing, you know, upfront, like before you have any surgeries, the biggest thing is, are you going to be, are you realistic with what your goals are? You know, if you are a massive weight loss patient or have breastfed, your natural tissue is not going to be as strong as it used to be. It's going to be very stretchy, or what we say elastic, and it can't even accommodate a bigger implant. And that's, in my opinion, that's the surgeon's responsibility up front to say, you know, no, you shouldn't be doing, you shouldn't, you can't achieve this, because then, unfortunately, I think a lot of patients may go somewhere else, and that other surgeon will say, oh yeah, let's do it, and then they have the problems, but that's the surgeon's responsibility to know, you know, I do a lot of breast surgery, and I can tell if their skin's going to accommodate something or not going to accommodate something, and I tell patients, like, you can't, it's just not possible. So, you know, I think it's a little bit of due diligence on our end as well to educate these patients on why they shouldn't upfront before they have anything done, and tell them you know you can't do this or you shouldn't do this because of xyz.

Dr. Jason Hall:

18:45

What would you say is a good take-home message at the end of this for women who are looking for, looking at, interested in breast augmentation and looking to get implants that may push the boundaries a little bit.

Dr. Jessica Walker:

19:02

One thing you know, I always mention: always make sure that you do your own research. I think you should make sure you see a board-certified plastic surgeon who is going to listen to you, but also educate you and knows you know what's going to happen down the road. And think about that, think about what can happen down the road in 10 years, in 20 years, like, do I still want this? Am I going to have neck and back pain? And for women to talk to somebody who's older than you, that does have large breasts, or anybody who needs a breast reduction, they will always tell you, don't do it. You know, you have to think long-term goals, not just short-term goals, and what's going to change about your anatomy, and in the end, like I said, unfortunately, breast surgery is not with an implant, is not a one and done, that you're going to have a revision at some point, and are you going to be limiting yourself and causing more problems if you go with too big of an implant?

Dr. Jason Hall:

19:55

Yeah, I think that's, I think that's a, that's a great point, is, is think past. Each trip, yes. Think, think 10 years down the road, not six months down the road,

Dr. Jessica Walker:

20:05

right. And I always tell my patients that that's something we talk about in our consultation. The one thing we talk about, kind of just implant, you know, pros and cons, and you are going to have another if you are very young, especially, you know, getting implants, you are very likely going to have another surgery related to your breasts, whether you want to go big or smaller, you know, need a lift, breastfeed, get pregnant, all those things. Are you going to be limiting your options down the road because of that, and then causing more problems with, again, neck and back pain, and finding bras that fit, finding clothes that fit, might be a limit. Can't wear button down shirts anymore, that's a lot of limits. Like, I want to be able to button a shirt, so that's things to think about that I don't think you know. We see on social media all the pictures in sports bras and in bathing suit tops and things like that, but a lot of problems, and I wear bras, they are hard to fit. It's hard to find one that fits good and is good quality and is the same. It's never the same in every story, you're a different size everywhere, so these are also things to think about. Is outside of what you're seeing on social media, and am I going to be comfortable with all this weight, added weight to your chest?

Dr. Jason Hall:

21:12

Yeah, another way social media is both good,

Dr. Jessica Walker:

21:15

yes,

Dr. Jason Hall:

21:15

and bad,

Dr. Jessica Walker:

21:16

yes.

Dr. Jason Hall:

21:16

So if you are interested in breast augmentation, interested in implant sizing, feel free to reach out to us, info at Trillium surgery.com You can get both of our, reach out to both of us through social media, links will be down in the show notes below. Thanks for watching. We'll see you on the next show, you.