How Implant Size Is Chosen for Direct-to-Implant Breast Reconstruction

One of the most common questions from breast reconstruction patients is: how do you decide what size implant to use? This applies specifically to direct-to-implant (DTI) reconstruction — where the final implant is placed at the time of mastectomy, rather than using a tissue expander first.

The very first question I ask every patient is: what size are you now, and do you like that size?

My implant choice in the operating room needs to reflect your goals and wishes. If you like the size you are, we aim for something similar. If you want larger or smaller, we plan accordingly.

After understanding your goals, I need to estimate your current breast size. I use a combination of:

• Physical examination
• 3D imaging (like Crisalix or Vectra) — which provides a volumetric estimation of your breast

Based on exam findings and volume estimation, I order a full cart of implants in various sizes and typically two different profiles so I have options in the OR.

The most important intraoperative measurement is the weight of the mastectomy specimen. After the breast surgeon completes the mastectomy, the specimen is weighed before going to pathology.

Through many years of experience with DTI reconstruction, I've found that using an implant that is slightly more cc's than the specimen weight in grams typically makes the patient feel about the same size as before. For example:

• 350g mastectomy specimen → ~400cc implant = feels about the same size

During your consultation, I do a sizing session where you can:

• View a 3D simulation of different sizes
• Try sizing cutlets in your bra to feel the added volume

If you decide you want 100cc more volume, then we take the mastectomy specimen weight, add a bit to match your baseline, and add the extra 100cc for your desired increase.

And yes, this is safe. My partner and I recently had a paper accepted showing that increasing implant size over mastectomy volume does not increase complications.

Interestingly, our research found that decreasing the size actually does increase complication rates. It's certainly still possible to downsize during reconstruction, but patients should understand the slightly higher risk.

Sizing for downsizing is also trickier — we rely more on simulation and cup size discussions rather than precise volumetric calculations.

Implant sizing for DTI breast reconstruction is a combination of:

• Your personal goals (same, bigger, or smaller)
• 3D imaging and exam for volume estimation
• Mastectomy specimen weight as the key intraoperative guide
• A full range of implant options available in the OR for real-time decision-making