Portal de Periódicos da CAPES

The Perfect Breast: Is It Attainable? Does It Exist?

2004; Lippincott Williams & Wilkins; Volume: 113; Issue: 5 Linguagem: Inglês

10.1097/01.prs.0000111881.35165.28

1529-4242

Garry S. Brody,

Digital Imaging in Medicine

While planning the program for the first breast symposium held in Santa Fe, New Mexico, in 1986, Harvey Zarem and I felt that a scholarly presentation on the aesthetics of that organ would keynote the underlying goal of all plastic surgery of the breast. Thus began a challenging search for such an expert. Surprisingly, a review of the anthropology and art literature resulted in a blank. It appeared that there had never been a scholarly anthropomorphic study or artistic analysis of the breast. Nor had there even been a valid statistical evaluation of the range and distribution of breast sizes and shapes. Telephone calls to the art and anthropology departments of several major universities did not result in anyone admitting to enough authority or interest to present the subject. Eventually I was referred to an unexpected source: the curator of costumes and fabrics at the Los Angeles County Museum, Dr. Edward Maeder. My call piqued his interest and resulted in a fascinating and scholarly presentation. His basic premise stemmed from his observation that the rendition of the nude female breast throughout the history of art reflected how the clothing of the specific time, place, and culture of any given historical era shaped the bosom. He presented a convincingly large number of examples. To underscore his point, he showed a slide of a sculptured nude that he had recently seen while visiting another museum. By merely looking at her breasts, he accurately placed the date and geographic origin of the piece! The plastic surgery literature is not, of course, devoid of articles on breast aesthetics. Many years ago, after measuring a series of student nurses, Jack Penn of South Africa determined that the ideal bosom described an 8- to 8½-inch equilateral triangle from the sternal notch to the nipples. 1 (I must admit that my personal recollections of student nurses from the same long ago era as Jack Penn's study suggested that they did not demonstrate such uniformity. I was perhaps a less objective observer.) John Tebbetts is currently the most vocal proponent of a formulaic algorithm for correct implant size and shape and has extensively proselytized the use of chest/breast ratios. He has repopularized the teardrop-shaped implant and has been instrumental in the design of the McGhan product. As we know, the face has been extensively measured and analyzed, and there are common basic dimensional relationships among features that have been considered attractive across time, cultures, race, and ethnicity. There are, however, no measurable aesthetic standards for the breast, undoubtedly due to its deformability from posture, arm position, and clothing. The breast is also the most changeable organ in the body, altering with puberty, weight gain and loss, hormonal balance, pregnancy, lactation, menopause, and just plain age. Just in the last hundred years, the idealized breast shape has gone from the Victorian "monobosom" to the boyish flapper to Jane Russell's full-breasted look to today's Pamela Anderson–like, contractured "Bay Watch" globules. While we surgeons bemoan our capsular contractures, the public hailed the advent of the Wonderbra, which was specifically designed to mimic the appearance of a Baker grade IV outcome. How many of our Hollywood starlets and fashion models proudly display their hemispherically augmented bosoms complete with full sternal separation incapable of contact cleavage? Today's "hard body" aesthetic is 20 pounds lighter than that in the Jane Russell era, making the implant even more obvious. This would be the converse of Maeder's premise, that is, a brassiere designed to mimic the shape of the breast. A recent study by Hsia and Thomson in Plastic and Reconstructive Surgery2 demonstrated "that plastic surgeons and patients seeking breast augmentation may have drastically different images in mind of what constitutes an attractive, natural, and ideal breast shape." A successful cosmetic operation should be marked by the patient's satisfaction with his or her own self-image. It is impertinent for us plastic surgeons to play Henry Higgins to our Eliza Doolittle patients by applying our own sense of aesthetics to the final outcome, even if we had the ability to accurately sculpt the final outcome. The engineering of the idealized, well-supported, natural breast is complex and difficult to mimic. It is made up of soft, physically amorphous tissue semiconstrained by Cooper's ligaments and the skin envelope. Its shape and relative position vary with posture. When supine, they assume a more globular shape; the base widens, projection flattens, and they fall to the sides. In the lateral decubitus posture, they respond to gravity, resulting in asymmetry of shape and location. When leaning forward, the envelope again becomes more hemispheric or even tubular, but the base narrows. From a materials perspective, the resources available to reproduce or replace the natural breast are indeed primitive. The engineering of the interaction of the glandular, stromal, fatty, and ligamentous components is so complex as to belittle our simplistic fluid-filled bag. Even our skin has far more complex elastic properties than any manmade composite. Add to that the vagaries of wound healing and the forces constantly being applied to all tissue by motion, stretching, compression, gravity, hormonal influences, and aging and one wonders why we even try to mimic nature. The implant selection currently available for augmentation and reconstruction permits at best the creation of a natural (aesthetic?) breast in only one posture—erect with arms down. Any ability to obtain contact cleavage or the natural postural shape changes is related more to the relative volumes of breast and implant and how little the device interferes with the extant normal tissue's mobility. Hence, all of our literature and standard photodocumentation consists only of five views of the same pose. Our surgical ego demands that we play a role in the final outcome, and indeed we do, but our options are limited in any given patient to the anatomy and biology at hand. How much control do we really have over the outcome of an augmentation? In truth, I believe, very little, as the final shape of the augmented breast is dependent on the interaction of three anatomical variants: chest, breast, and implant, as well as the individual woman's biological response to the device. The only thing that we can guarantee is a volume increase. Chest Wall Anatomy I am always surprised to note the remarkable number and variety of thoracic contours that I detect after careful examination of my augmentation candidates. The plane of the anterior chest determines the direction that the breast expands. A rounded anterior thorax bases the breast from 30 to 45 degrees off of the sagittal plane, so that the nipple rides laterally as the breast enlarges. Chest wall deformities and asymmetries are common. A severe pectus excavatum can actually tilt the breast medially. A mild degree of scoliosis and shoulder level discrepancy is not uncommon. It is usually reflected in the anterior rib cage and breasts by some degree of asymmetry and/or deformity. A concave anterior chest wall with a flared rib margin absorbs a lot of breast (implant) volume in the hollow before it contributes to projection, while a barrel chest can give the illusion that the breasts are larger than they are. The Existing Breast As with any paired organ or anatomical site, true bilateral symmetry does not exist. Unequal shoulder height can lead to apparent nipple height discrepancies and yet demonstrate equal measurements from the clavicle or manubrium. Careful examination of the breasts will demonstrate bilateral differences of some degree in all women. Today's aesthetic ideals demand a much leaner body, often reflected in less breast mass and thus emphasizing any contracture. Unless these are significant, most women are as unaware of their differences as they are of their facial asymmetry—at least before the surgery. Prudence suggests that prospective patients be made aware of their anatomical variances preoperatively, as the postoperative result is often more minutely scrutinized than their original anatomy. The Implant The smallest surface area to contain a given volume of fluid is a sphere. An inelastic plastic bag filled to capacity will feel firm, but if fluid is removed without a change in capacity, the bag becomes progressively more ovoid and softer. So, too, all implant shells are underfilled by virtue of their aspherical shape. A compromise must often be struck in filling the device between minimizing the volume of saline for softness versus adding fluid to minimize wrinkling and influence shape. Similarly, the scar capsule must be very elastic or oversized to avoid compressing the implant. Therefore, no matter what the shell shape is, with normal fill the implant will be somewhat distorted toward the smallest surface area by scar contracture or gravity. John Tebbetts has extensively described his concept of the interrelationships of the anatomical measurements of the breast and chest and has devised a comprehensive chart to record all the data. He feels strongly that the implant's shape and dimensions are important contributors to the final outcome. I have personally abandoned that approach as I have found that the interaction of the chest, the breast, the implant, and the healing process does not seem to care much about my preoperative plans. Examination of implants excised with intact capsules reveals that they have assumed unpredictable shapes very different from the surgeon's intent. I have seen oval, triangular, teardrop, and many irregularly shaped specimens. This may explain the controversy over whether the shaped implant truly performs as advertised. Fortunately, for the most part, the overlying breast tissue, depending upon the amount, will mask many of these irregularities. I suspect that if we were able to create a cast of the capsule, we would rarely find it conforming to the intended shape of the implant. Thus, it is my conviction that the breast and wound healing shape the implant rather than the implant shaping the breast. What about Softness? Certainly, the Baker I ideal implies a "dead soft" breast, but the ultimate feel often depends upon the amount of native breast and the size and firmness of the implant it covers. The polyurethane-coated and the newer cohesive gel devices tend to have a "doughy" feel. Theoretically, they are still enough to splint the capsule and resist contracture and deformation. Only physicians who examine the breasts of countless women have enough experience to appreciate the spectrum of densities of the normal organ. Fortunately for our limited abilities to control the true feel, most people gain their sense of breast texture from their personal contacts, which are relatively limited. One of my patients suggested that the true criterion is the "hug test." Can the hugger tell that the huggee has implants? Implant Size Selection The only variant over which we have absolute control is size. In the trade-off between size and softness, today's woman, influenced by current fashion, will chose size 98 percent of the time. Using the Tebbetts formula, our volume options are limited by our patient's preoperative measurements. He has declared that he will never insert an implant larger than 350 cc. But if Hsia and Thomson are correct, is this not playing Pygmalion? There are an infinite number of social subsets among our patients with varied motives and aesthetic ideals. Are we here to please our personal aesthetic sense or to attempt to satisfy the patient's self-image? I strongly believe that the patient should be the sole arbiter of her breast size. In my practice, I share with the patient the consequences of any chosen size as best I can, but the final decision is hers! To accurately select the correct size, she is asked to buy a brassiere she would like to fill, stuff it, and wear it around the house for a few days to evaluate the look acquired. It is then a simple thing to measure the volume required to fill the cup with a plastic bag of water or rice. Since adopting this approach, my average implant size has risen from 300 cc to 450 cc. 3 This does not necessarily mean that anyone who walks in the door gets any extreme she wants. In the background, of course, is the evaluation of all cosmetic patients for their motives, maturity, and psychological appropriateness. Returning to the original theme of the opening paragraph, it appears that, fortunately for us, the outcomes that we are able to obtain with our inadequate attempts to recreate the "natural" breast have created the current fashion in breast aesthetics. At the moment, size is paramount; the new shape is second (as the brassiere can adjust for a lot of variation), followed by softness. As predictably creating a totally "natural" breast is beyond our current technology, woe to us if and when the new aesthetic fad becomes a return to whatever nature planned for each individual. To paraphrase the Bard, "beauty is in the eye of the beholder—the patients." Thus, the answer to the question posed by the title is, It depends!