BRODY'S ARTICLE ON THE PERFECT BREAST

[LETTERS AND VIEWPOINTS: LETTERS]

Teitelbaum, Steven A. M.D.

1301 Twentieth Street, Suite 350, Santa Monica, Calif. 90404-1208

Sir:

I am a grateful former resident of Dr. Garry Brody, but I respectfully dare to take issue with my mentor on his editorial, The Perfect Breast: Is It Attainable? Does It Exist? (Plast. Reconstr. Surg. 113: 1500, 2004).

It is an interesting choice of words to write that a colleague has extensively proselytized the use of chest/breast ratios. Proselytization is imposing your faith upon another. However, this surgeon has published extensive quantitative analysis of breast augmentation surgery. Dr. Brody uses this word to pejoratively dismiss conclusions that were based on quantified empiric data. The triumph of data over faith is what distinguishes science from all other intellectual endeavors. If we are to even pretend we are scientists, we must avoid using our own beliefs to condemn empiric data.

Dr. Brody argues that since we cannot define the perfect breast, and since we have no meaningful control over breast shape, we should focus only on volume. But even though we might not be able to define the standard perfect breast shape, we can look at an individual patient's breasts and identify what would make a better breast shape for her. And even if we cannot all agree about what would constitute a perfect or better breast shape, we should agree about unattractive breast shapes (e.g., visible edges, disproportion, and stretch deformities). Avoiding these (often uncorrectable) iatrogenic deformities should be as important as striving for the perfect shape.

I have seen that my operative choices do profoundly affect long-term breast shape (e.g., implant shape, size, fill, and projection; pocket location; parenchymal scoring; and so on), as well as the need for secondary surgery. I have also observed that when tissue characteristics are ignored for the sake of size, unattractive deformities are more likely to occur. My experience is different from that of Dr. Brody: I believe we can improve breast shape (and damage it as well). Dr. Brody is correct that this shaping power is limited, but it is sufficient to allow us to be breast shapers and not just breast stuffers.

He is correct that existing implants give limited control over shape. As an investigator in both the Inamed and Mentor core trials of form-stable cohesive silicone gel-filled implants (the 410 and the CPG), I can report that rather than being subject to deformation by gravity and the forces of the breast, these implants maintain their shape and impart it upon the breast. We are at the dawn of an era in which we will have an unprecedented ability to control shape. That is why Dr. Brody's editorial is so timely.

Dr. Brody says that we should not be playing Pygmalion when it comes to choosing size, but instead allow our patients to pick the volume that they wish to have. I disagree. I feel it is not merely appropriate but ethically mandatory for us to detail the trade-offs of Brobdingnagian augmentations to patients. After discussion of these issues, I have had only the rare patient choose implants as large as those he commonly uses. While traction rippling, visible edges, excessively lowered inframammary folds, parenchymal atrophy, synmastia, bottoming-out, and stretch deformities requiring mastopexy are all possible with moderate-size implants, these problems are exacerbated by implant size. Discussing these topics is not playing Pygmalion; it is achieving informed consent.

I think that when patients size themselves by filling a brassiere until they achieve their desired appearance, they risk being overaugmented. As Dr. Brody discussed, clothing extensively shapes the bosom and a society's concept of the ideal breast. Even the Wonderbra comes in a 38D! The goal many patients have today is, as Dr. Brody would agree, one dependent on the amplifying effects of these brassieres. If a patient fills up a standard brassiere until she achieves that look, she will be asking for more volume than necessary. If natural D-cup women wear these brassieres, why cannot augmented women?

Dr. Brody tells us not to be a Henry Higgins to our Eliza Doolittle patients. I suppose if one thinks that Eliza would have been better off if she had remained on the street as a flower peddler, then one should acquiesce to patient size requests without regard for tissue characteristics. I, for one, feel that Henry Higgins improved Eliza Doolittle's life, and I am not ashamed to offer patients my opinions as to the consequences of their choices.

Steven A. Teitelbaum, M.D.

1301 Twentieth Street, Suite 350, Santa Monica, Calif. 90404-1208