Patients often come in asking for improvements in symmetry. Sometimes, they request perfection. And this reminds me of a saying we commonly express as plastic surgeons to our patients, “The enemy of good is great”.
This is not to say that cosmetic surgeons shouldn’t strive for greatness in every procedure or surgery they perform. In fact, it is the goal of every operation to achieve the very best result. However, sometime the chase for perfection isn’t worth the potential risk or “damage” to the patient. More times than not, the difference between a very good results and a great or “perfect” result involves maneuvers that just aren’t worth it. And its often hard to convey this rule to the patient when all they can see is the dream of perfection.
Examples are boundless of this principle, but here is one to digest. Let’s say a woman comes in for a breast augmentation. I always ask, “Which breast is larger, do you know?”. More than half of the time, a woman will immediately point to a side and with conviction declare it is the larger breast. And they are almost always correct. Women know their breasts.
Then I often then ask, “What nipple is lower?” And rarely do they know unless it is very obvious. After the standard breast measurements are taken as illustrated here from a recent breast augmentation consultation, they are reviewed with the patient.
In the diagram below, the V sitting on top of the triangle represents the notch above the rib cage, referred to the suprasternal notch. The two dots represent the nipples. The numbers are the measurements in centimeters.
The arrow pointing downward represent the distance from the nipple to the fold of the breast. And the horizontal line represents the width of the breast.
From the measurements of this patient, one can see that the variation between both sides are very small. Yet, they are still large enough for her to appreciate asymmetry. While there is no good three dimensional analytic tool to evaluate breast volume (size) it was clear that upon inspection that her left side was also larger — but barely larger.
In planning for her augmentation, she requested “perfect symmetry”. However, breast augmentation just adds volume (and to some degree, “shape”, depending on the implant style chosen.) For perfect symmetry, the breast folds and nipple positions would need to be altered, and the volumes of the implants would need to be different — by some degree which is largely unknown.
This is when it time to put on the brakes as a plastic surgeon and give the “enemy of good is great” lecture. While nipple position and folds can be altered, it certainly isn’t worth the scars and potential complications that accompany these surgical maneuvers. And it still won’t make everything symmetrical because there are tissue dynamics and healing at play which can be highly unpredictable. And this is the lesson of just about every cosmetic surgery performed.
This principle becomes critically important in the post operative period, where patients have a very good result but request an improved (ie. “perfect” result). Sometimes, the quest for perfection can put patients in harm’s way. It could mean creating a deformity in liposuction. It could mean poor healing or tissue loss in the breast. Or it could mean infection from an otherwise unnecessary surgery landing a patient in the hospital.
An experienced surgeon knows when the risks outweighs the benefits. He or she knows that symmetry, while often desirable, isn’t achievable. And the experienced surgeon knows how to walk the patients through the scenarios that force them back on track to accept a very good result.
Dr. Tim Neavin is a board-certified plastic surgeon located in Beverly Hills, California.