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Cosmetic breast surgery encompasses a wide array of procedures from the placement of implants, lifts, reductions, liposuction and fat grafting. This is not to mention another list of potential changes that can be done to the nipple-areolar complex with or without concomitant mound reshaping. But what makes breast reshaping surgery a very unique collection of procedures is that there are two paired breasts and they sit side by side. This makes comparing the surgical results of both breasts unavoidable.

Patients would like and expect near perfect symmetry in their breast surgery no matter how comparable (or not) that they were before. But the reality is that few breast surgeries result in ideal symmetry between the paired structures no matter how well executed the surgery is. Tissues mend, scars mature and breast skin relaxes differently as they heal. Even though the breasts are still next to each other in plain view during surgery and the exact same procedure may have been done to both (e.g., breast implants, breast reduction) that does not always guarantee ideal symmetry after surgery.

One of the main reasons is that most women have some degree of congenital breast asymmetry. It may be very slight and often unnoticed, particularly if the breasts are small, but it is almost always there. When the breasts become enlarged during augmentation, what was once a slight and unnoticeable difference can now become more magnified and apparent…often prompting the thought or statement from the patient…how could this happen? (thus the value of before surgery pictures and the pointing out of any asymmetry in the mounds and nipples beforehand) Mathematical operations such as lifts and reductions will have presurgical markings that are identical in all dimensions and this can certainly improve many pre-existing significant breast asymmetries. But the healing process rarely responds in a predictable measurable way. The amount of bruising, fluid collections and tissue reactions at the suture lines all control how the mound will end up being shaped and the scars will look.

These breast surgery considerations brings me to the concept of ‘sister surgery’, which is well known amongst plastic surgeons. This is the reality that perfect breast symmetry should not be expected after any breast reshaping surgery. They may look somewhat similar, like sisters, but they are not going to be identical twins when all healing is done. This may seem to set the bar for expectations as fairly low, but it is an unavoidable reality. I certainly have seen numerous breast surgeries that looked about close to ideal as possible but this is more uncommon than common.

The sister concept most certainly is evident right after surgery and during the weeks to months that follow as they heal. They never look the same even if it is as straightforward as just the placement of breast implants. This is why one shouldn’t be too critical right after surgery. It will take up to three months, regardless of the breast procedure performed, to make a final judgment as to the shape and symmetry between the breasts. This is why revisional breast surgery should wait at least three months after surgery before doing a critical comparison of the two sisters.

Dr. Barry Eppley

Indianapolis, Indiana

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