Bra Stuffing for Implant Sizing? Satisfaction? Who, When, and Compared to What?

Sir: I am writing regarding the article entitled “Preoperative Sizing in Breast Augmentation” published in the June of 2010 issue (Plast Reconstr Surg. 2010;125:1781–1787). The authors characterize their bra stuffing implant sizing methodologies as “simple” and “accurate.” Simple? Up to three visits to the surgeon's office to ruminate over shades of gray using a totally subjectively derived decision process based on indefinable cup size parameters and the patient's visual perceptions? Accurate? Thirty percent of sized respondents reported that the sizing methods were inaccurate. Choosing breast implant size by bra stuffing has a repetitive, three-decade track record of 15 to 25 percent reoperation rates (and a major percentage of reoperations for size change) in the most stringent, independently monitored U.S. Food and Drug Administration premarket approval studies, which are substantially more scientifically robust compared with anecdotal survey series. The authors' implication that objective, scientifically validated, defined-process implant selection methods1,2 preclude or minimize patient involvement in the decision-making processes is misguided and incorrect. The level of patient involvement in the patient education and decision-making processes documented in current peer-reviewed and published studies in this Journal1–4 is currently unmatched in the world literature with respect to content, comprehensiveness, and scientifically validated efficacy, outcomes, and reoperation rates. Those methodologies produced the only 0 percent reoperation rate ever reported at 3 years from an independently monitored U.S. Food and Drug Administration premarket approval study.4 Optimally educated patients rarely opt for bra stuffing size selection when they are aware of alternatives and understand that objective, scientifically validated methods exist and have been shown in peer-reviewed and published studies to deliver the most rapid recovery, the lowest reoperation rates in independently monitored studies,4 and the lowest incidence of uncorrectable tissue deformities. Armed with that knowledge, most patients rationally temper their wishes with what is best in the long term for their tissues. Absent that knowledge and an opportunity to use those methodologies, patients and surgeons historically revert to intuitive, subjective, and outdated methodologies that make them feel temporarily comfortable and “satisfied,” although those same “satisfied” patients report in this study that the methods are only 70 percent accurate. Other issues with this article include the following: Statistical analysis does not accord scientific validity to data when survey methodologies and questions were not validated initially. References and discussion conveniently omit U.S. Food and Drug Administration premarket approval data that have shown for more than three decades that the methodologies advocated in this article generated consistently excessive reoperation rates of 15 to 25 percent or more. Satisfaction of 142 respondents with bra stuffing at a median 12 months postoperative hardly implies any substantive outcomes information that substantively affects patients' welfare. Subjective methodologies for implant sizing are nonscientific, not reproducible, not consistently transferable, and difficult to defend medicolegally because the very definitions on which they are based (cup size) are not definable. Patients cannot be held accountable for decisions using parameters that neither surgeons nor patients can define. Forcing breast tissues to a subjectively defined, desired result instead of allowing objective, scientifically validated measurements and methodologies to drive a much more predictable and reproducible decision process and outcomes guarantees tissue and aesthetic compromises. The surgeon, not the patient, choosing “most often a C cup, although a D cup may be used in some young nulliparous patients and a B cup in some older and more conservative postpartum patients.” The former is more likely to force nulliparous tissues to a temporary result that may later result in irreversible stretch, tissue thinning, and parenchymal atrophy; and the latter is likely to inadequately fill a parous envelope and produce a “rock-in-a-sock” empty upper breast in the longer term. Encouraging patients to believe that they can simply choose what they want, regardless of their quantifiable tissue characteristics and the consequences of their wishes on their tissues in the long term. Basing implant size decisions on height, weight, hip width, “personality,” and geographic demographics, when none of those parameters has anything to do with the dimensions and tissue characteristics and limitations of the tissues that exist on the breast. Concluding that a methodology is “reasonably accurate,” when 30 percent of sized respondents said it was not accurate, uses the very data in the article to disprove the article's conclusions. Seeking to resurrect and validate an obsolete, subjective methodology based on indefinable cup size parameters using a 52.5 percent response rate of 142 respondents, 30 percent of whom, despite their supposed satisfaction, reported that the sizing methodology is inaccurate. The sad story for patients is that surgeons continue to promote four-decade-old subjective methodologies and try to tell the old story with a different (“patient satisfaction”–oriented) twist, when existing peer-reviewed and published studies prove the inadequacies of those outdated methodologies, and especially when other peer-reviewed and published studies, independently monitored, offer methodologies with proven superior processes and outcomes.1–4 Satisfaction? Who is satisfied, when, and compared with what? Seventy percent accuracy may satisfy some patients, but it should not satisfy any surgeon. I trust that informed patients and surgeons will not be satisfied with reverting to four-decade-old methodologies based on a small series of survey respondents at a median 6-month response time when 30 percent of sized respondents stated that the methods did not accurately predict their size. The authors concluded that “It is expected that future improvements in methodology and equipment will improve the precision of the technique.” I could not agree more, but the “future” was 4 years ago, the required equipment is a measuring tape, and the methodologies and processes are peer-reviewed and published in this Journal.1–4 John Tebbetts, M.D. 2801 Lemmon Avenue West, Suite 300 Dallas, Texas [email protected]