Invited commentary: Ideal anthropomorphic values of the female breast: correlation of pluralistic aesthetic evaluation with objective measurements.

Pursuit of a reliable quantitative aesthetic breast ideal has been elusive, and at times controversial. 1,2 For decades, many surgeons have based their operative planning on outmoded anthropometric guidelines derived from a homogeneous sample of a single surgeon's aesthetic ideal. 3 Although these measurements have been useful for approximation, they are relatively crude and cannot be applied with great reliability to patients of varying body habitus. They do not take into account certain volumetric attributes or anatomic characteristics that would maximize individual patient aesthetic desires or outcomes. In an attempt to make sense of the human gestalt, Liu and Thomson 4 have taken a more egalitarian and sophisticated approach in assessing and defining the ideal breast anthropometrics. The authors set out to define ideal aesthetic standards by querying cosmetic and reconstructive patients as well as plastic surgeons, and to distinguish possible biases harbored by plastic surgeons. They cite, and we agree with, the importance of gaining aesthetic input from the patient. The authors contend that their study is more robust and comprehensive than that of older reports. 3,5―8 They attempt to quantify ideal anthropometric values of the breast by correlating the aesthetic evaluations of many with measurements taken from 109 female volunteers. In doing so, plastic surgeons are ultimately provided with a set of optimized values from an aggregated source. This is in contradistinction to historic average anthropometric values taken from the general populace without regard for aesthetics, or measurements derived from singular opinion of aesthetic ideal. 3,5 Arguably, there are some shortcomings in the methodology of this study. A random sample of pictures was shown to 252 plastics surgeons, 15 cosmetic breast patients, and 25 breast reconstruction patients. The authors state that the evaluations were uniformly distributed across all breasts with each breast pair evaluated 41 times. There is a large discrepancy in the number of times the breast pairs were analyzed by each type of evaluator: 3641 (14.5 pair/surgeon), 368 (24.5 pair/cosmetic patient), 437 (17.5 pair/reconstructive patient). Many more breasts were, therefore, evaluated by trained plastic surgeons. Because anthropomorphic measurements differed so little between the 3 evaluator types, this discrepancy should not have affected the ideal measurements. In all, 47% of the subjects had prior breast surgery. Assuming a uniform distribution, 47% of evaluated breast pairs were subject to evaluator bias as it relates to surgical scar, nipple shape, color, and various postsurgical contour deformities. Unlike the layperson, the plastic surgeon may be able to recognize these issues and disregard them in the same way the authors have asked the surgeon evaluators to ignore breast size. Alternatively, surgeons may assign an artificially inflated aesthetic score to postsurgical patients on the basis of understanding the limitations and sequelae of surgery. Ideal measurements were derived from evaluators' responses to the electronic survey. Those images wherein vertical and horizontal nipple position and areolar size were deemed "normal" served as the basis for these calculations. In our view, it can not necessarily be presumed that "normal" vertical and horizontal nipple position can be translated into "ideal. " Aesthetic scores were only used to grade the nonanthropometric measurements of asymmetry and cleavage in the nonsurgeon evaluators. Interestingly, the authors included the evaluation of ptosis in surgeons' questionnaires only. The authors designated "no ptosis" as the aesthetic ideal and generated additional measurements on the basis of these data. Predictably, lower aesthetic scores were elicited with increasing grades of ptosis. In this way, the authors have preselected the particular evaluator group, biased by their training, to equate higher degrees of ptosis with a lesser aesthetic ideal. It would be interesting to explore this characteristic with nonsurgeon evaluators to assess whether their notions correlate with surgeon dogma. Reconstructive patients were noted to have the greatest concern about asymmetry. Inherent bias may exist in this evaluator group based on focused preoperative discussions surrounding the inevitability of some degree of postoperative asymmetry.