Keywords
ideal breast size ideal areola size aesthetic breast
Introduction
Patients have long desired an augmentation in breast size because of inadequate development,
asymmetry, or loss of volume after pregnancy. It is therefore important to define
and correctly determine the optimal female breast and aesthetic proportions, in order
to prepare for surgery, set targets of surgery, and evaluate surgical outcomes. Leaving
the decision to the operating surgeons alone might leave disappointing results, which
especially leads to reoperation, quite often in the aspect of breast dimension.[1]
There are, nonetheless, no assessable aesthetic criteria for the breast, certainly
owing to its deformability from stance, arm position, and clothing. The female breast
is also the most changeable organ in the body, altering with puberty, weight, hormonal
balance, gestation, lactation, and natural aging.[2] Patient contentment should be the pertinent criterion and not what the surgeon deems
as natural and normal, either in size and form.[3] Therefore, this preliminary study is conducted to provide an initial insight into
ideal female breast size to assist plastic surgeons and potential patients in deciding
their surgical outcome.
Materials and Methods
This study was conducted using an online graphic questionnaire at Hospital Universiti
Sains Malaysia (HUSM) to seek the most ideally perfect size of female breast and nipple-areola
complex (NAC) from the general community and attempt to associate with their sociodemographic.
The participants were recruited from a general community in the HUSM compound, which
encompasses various ethnicities and social backgrounds via the convenience sampling
method. An electronic medium was utilized to prevent unwanted disadvantages with printed
paper such as higher cost, stain, and tear. The breast photographs of the questionnaire
were drawn on an empty canvas by Photoshop Studio CS4, with various editing tools
to attain the various desired qualities. Finally, the portrait drawings were transformed
into black and white photographs to remove possible biases, resulting from colors
in skin tone. The upper body was presented from the neckline to the lower border of
the lower rib to eliminate the probable effect of waist circumference on attractiveness
scores.
The NAC component was set to five panels, which were 15 mm, 20 mm, 30 mm, 40 mm, and
45 mm in diameter, to be the basic framework (
[Fig. 1] A). The NAC was cropped out of the created drawing, and size adjustments were made
(enlarge and shrink) before it was blended back into the original drawing. For breast
size component, commonly, the plastic surgeon interacts with patients seeking breast
augmentation, according to the cup size, even though it is not constant with various
band sizes.[4] A typical C cup size has 22.5 cm of hemicircumference and 7.35 cm of the nipple
to inframammary fold length, and the usual volume to increase one cup size was in
the range of 130 to 205 mL.[5]
[6]
[7] For simplicity, breast C cup size was taken as approximately 500 mL volume for a
guideline, although it was recognized that it may vary among individuals of the same
cup due to alterations in the underband size and various breast implant brands.[7]
[8]
[9] Thus, this component was set to six panels, which were size A: 100 mL, B: 300 mL,
C: 500 mL , D: 700 mL , DD: 900 mL, and E: 1100 mL, to be the basic framework (
[Fig. 1] B). Similarly, the breasts were cropped out of the created drawing and manipulated
(resize, enlarge, and shrink) before the breasts were melded back into the original
drawing. These photographs were drawn from the front view to demonstrate the size
of both breasts in the erect position. Other body features such as the position of
the NAC and the body shape remained consistent to prevent assessment bias to different
shapes of the torso (e.g., body mass index [BMI]). The photograph panels of each component
were piled on each other and displayed as one screen page, and the explicit labels
(e.g., 30 mm, size C cup) were hidden to prevent selection bias. The participants
were asked to select only one photograph that has the most attractive look of all
panels for both NAC and breast size components. Descriptive analysis was conducted
to define the preference of an ideal NAC and breast size. By using STATA 15, Fischer’s
exact test was employed for each association of breast components and its sociodemographic.
Fig. 1 Drawn image panel from front view showing from the left. (A) The size of nipple-areola complex (NAC) 15 mm, 20 mm, 30 mm, 40 mm, and 45 mm; (B) the breast size cup A, B, C, D, DD, and E.
Results
Sixty-eight men and 67 women participated in the survey. The mean age was 34.67 years.
Fifty-five participants (40.7%) were between the ages 18 to 29 years, 59 participants
(43.7%) were between the ages 30 to 49 years, and 21 participants (15.6%) were between
the ages 50 years and above. There was an identical proportion of the main racial
component of Malay, Chinese, and Indian (31.1%). Twenty-seven participants (20.0%)
worked in the health care sector ([Table 1]).
Table 1
Descriptive analysis of sociodemographic of the participants (n = 135)
Variable
|
Frequency (%)
|
Age (years)a
|
34.67 (12.00)
|
Age group (years)
|
|
18–29
|
55 (40.7)
|
30–49
|
59 (43.7)
|
≥ 50
|
21 (15.6)
|
Gender
|
|
Male
|
67 (49.6)
|
Female
|
68 (50.4)
|
Race
|
|
Malay
|
42 (31.1)
|
Chinese
|
42 (31.1)
|
Indian
|
42 (31.1)
|
Others
|
9 (6.7)
|
Education level
|
|
Primary/secondary
|
49 (36.3)
|
Tertiary
|
75 (55.6)
|
Postgraduate level
|
11 (8.2)
|
Occupation
|
|
Unemployed
|
24 (17.8)
|
Self-employed
|
18 (13.3)
|
Retired
|
6 (4.4)
|
Health care sector
|
27 (20.0)
|
Nonhealth care sector
|
60 (44.4)
|
Marital status
|
|
Single
|
71 (52.6)
|
Married
|
62 (45.9)
|
Widower
|
2 (1.5)
|
The highest proportion of NAC size and breast size preferred among the participants
was 30 mm (43.0%) and breast size D cup (37.8%), respectively ([Table 2]). There was no significant association between NAC size and their sociodemographic
([Table 3]). From the Fischer’s exact test, there was a significant association between breast
size and gender (p = 0.023), with those preferring D cup being higher among males compared with females
(59.6% vs. 40.4%), whereas those preferring C cup being higher among females compared
with males (62.8% vs. 37.3%). There was no significant association found between other
demographics and breast size ([Table 4]). It was noted that most of the Malays and Chinese preferred breast size C cup,
while Indians were more inclined to a D cup size. Younger participants (18–29 years
old) favored the C cup, similar to most of the single individuals, whereas the 30
to 49 years group preferred the D cup, like the majority of married individuals.
Table 2
Descriptive analysis of ideal breast preferences (n = 135)
Breast appearance
|
Frequency (%)
|
Abbreviation: NAC, nipple-areola complex.
|
NAC size in diameter (mm)
|
|
15
|
13 (9.6)
|
20
|
37 (27.4)
|
30
|
58 (43.0)
|
40
|
21 (15.6)
|
45
|
6 (4.4)
|
Breast size
|
|
Size A cup
|
5 (3.7)
|
Size B cup
|
12 (8.9)
|
Size C cup
|
51 (37.8)
|
Size D cup
|
52 (38.5)
|
Size DD cup
|
9 (6.7)
|
Size E cup
|
6 (4.4)
|
Table 3
Association between areola size and sociodemographic (n = 135)
Sociodemographic factor
|
Areola size, n (%)
|
p-valuea
|
15 mm (n = 13)
|
20 mm (n = 37)
|
30 mm
(n = 58)
|
40 mm
(n = 21)
|
45 mm
(n = 6)
|
aExpected count of less than 5 was ≥ 20%; Fisher exact test was applied.
|
Age group (years)
|
|
|
|
|
|
|
18 – 29
|
6 (46.2)
|
12 (32.4)
|
22 (37.9)
|
10 (47.6)
|
5 (83.3)
|
0.479
|
30 – 49
|
4 (30.8)
|
17 (46.0)
|
28 (48.3)
|
9 (42.9)
|
1 (16.7)
|
|
≥ 50
|
3 (23.1)
|
8 (21.6)
|
8 (13.8)
|
2 (9.5)
|
0 (0.0)
|
|
Gender
|
|
|
|
|
|
|
Male
|
10 (76.9)
|
21 (56.8)
|
27 (46.6)
|
7 (33.3)
|
2 (33.3)
|
0.106
|
Female
|
3 (23.1)
|
16 (43.2)
|
31 (53.5)
|
14 (66.7)
|
4 (66.7)
|
|
Race
|
|
|
|
|
|
|
Malay
|
7 (53.9)
|
10 (27.0)
|
17 (29.3)
|
7 (33.3)
|
1 (16.7)
|
0.093
|
Chinese
|
3 (23.1)
|
16 (43.2)
|
20 (34.5)
|
3 (14.3)
|
0 (0.0)
|
|
Indian
|
2 (15.4)
|
10 (27.0)
|
17 (29.3)
|
10 (47.8)
|
3 (50.0)
|
|
Others
|
1 (7.7)
|
1 (2.7)
|
4 (6.9)
|
1 (4.8)
|
2 (33.3)
|
|
Occupation
|
|
|
|
|
|
|
Unemployed
|
0 (0.0)
|
6 (16.2)
|
12 (20.7)
|
4 (19.1)
|
2 (33.3)
|
0.380
|
Self-employed
|
1 (7.7)
|
8 (21.6)
|
8 (13.8)
|
1 (4.8)
|
0 (0.0)
|
|
Retired
|
1 (7.7)
|
3 (8.1)
|
1 (1.7)
|
1 (4.8)
|
0 (0.0)
|
|
Health care sector
|
4 (30.8)
|
5 (13.5)
|
9 (15.5)
|
7 (33.3)
|
2 (33.3)
|
|
Nonhealth care sector
|
7 (53.9)
|
15 (40.5)
|
28 (48.3)
|
8 (38.1)
|
2 (33.3)
|
|
Marital status
|
|
|
|
|
|
|
Single
|
7 (53.9)
|
21 (56.8)
|
29 (50.0)
|
10 (47.6)
|
4 (66.7)
|
0.966
|
Married
|
6 (46.2)
|
15 (40.5)
|
28 (48.3)
|
11 (52.4)
|
2 (33.3)
|
|
Widower
|
0 (0.0)
|
1 (2.7)
|
1 (1.7)
|
0 (0.0)
|
0 (0.0)
|
|
Table 4
Association between breast size and sociodemographic (n = 135)
Sociodemographic factor
|
Breast size, n (%)
|
p-valuea
|
A cup
(n = 5)
|
B cup
(n = 12)
|
C cup
(n = 51)
|
D cup
(n = 52)
|
DD cup
(n = 9)
|
E cup
(n = 6)
|
aExpected count of less than 5 was ≥ 20%; Fisher exact test was applied.
|
Age group (years)
|
|
|
|
|
|
|
|
18–29
|
1 (20.0)
|
8 (66.7)
|
25 (49.0)
|
18 (34.6)
|
2 (22.2)
|
1 (16.7)
|
0.175
|
30–49
|
2 (40.0)
|
3 (25.0)
|
17 (33.3)
|
28 (53.9)
|
5 (55.6)
|
4 (66.7)
|
|
≥ 50
|
2 (40.0)
|
1 (8.3)
|
9 (17.7)
|
6 (11.5)
|
2 (22.2)
|
1 (16.7)
|
|
Gender
|
|
|
|
|
|
|
|
Male
|
4 (80.0)
|
3 (25.0)
|
19 (37.3)
|
31 (59.6)
|
5 (55.6)
|
5 (83.3)
|
0.023
|
Female
|
1 (20.0)
|
9 (75.0)
|
32 (62.8)
|
21 (40.4)
|
4 (44.4)
|
1 (16.7)
|
|
Race
|
|
|
|
|
|
|
|
Malay
|
2 (40.0)
|
3 (25.0)
|
20 (39.2)
|
12 (23.1)
|
3 (33.3)
|
2 (33.3)
|
0.447
|
Chinese
|
0 (0.0)
|
5 (41.7)
|
18 (35.3)
|
16 (30.8)
|
2 (22.2)
|
1 (16.7)
|
|
Indian
|
2 (40.0)
|
4 (33.3)
|
12 (23.5)
|
19 (36.5)
|
3 (33.3)
|
2 (33.3)
|
|
Others
|
1 (20.0)
|
0 (0.0)
|
1 (1.96)
|
5 (9.6)
|
1(11.1)
|
1 (16.7)
|
|
Education level
|
|
|
|
|
|
|
|
Primary/secondary
|
2 (40.0)
|
4 (33.3)
|
25 (49.0)
|
12 (23.1)
|
4 (44.4)
|
2 (33.3)
|
0.293
|
Tertiary
|
3 (60.0)
|
7 (58.3)
|
24 (47.1)
|
33 (63.5)
|
5 (55.6)
|
3 (50.0)
|
|
Postgraduate
|
0 (0.0)
|
1 (8.3)
|
2 (3.9)
|
7 (13.5)
|
0 (0.0)
|
1 (16.7)
|
|
Occupation
|
|
|
|
|
|
|
|
Unemployed
|
0 (0.0)
|
4 (33.3)
|
8 (15.7)
|
9 (17.3)
|
2 (22.2)
|
1 (16.7)
|
0.300
|
Self-employed
|
2 (40.0)
|
2 (16.7)
|
9 (17.7)
|
3 (5.8)
|
1 (11.1)
|
1(16.7)
|
|
Retired
|
0 (0.0)
|
0 (0.0)
|
4 (7.8)
|
2 (3.9)
|
0 (0.0)
|
0 (0.0)
|
|
Health care sector
|
1 (20.0)
|
2 (16.7)
|
15 (29.4)
|
7 (13.5)
|
1 (11.1)
|
1 (16.7)
|
|
Nonhealth care sector
|
2 (40.0)
|
4 (33.3)
|
15 (29.4)
|
31 (59.6)
|
5 (55.6)
|
3 (50.0)
|
|
Marital status
|
|
|
|
|
|
|
|
Single
|
1 (20.0)
|
7 (58.3)
|
30 (58.8)
|
27 (51.9)
|
3 (33.3)
|
3 (50.0)
|
0.515
|
Married
|
4 (80.0)
|
5 (41.7)
|
19 (37.3)
|
25 (48.1)
|
6 (66.7)
|
3 (50.0)
|
|
Widower
|
0 (0.0)
|
0 (0.0)
|
2 (3.9)
|
0 (0.0)
|
0 (0.0)
|
0 (0.0)
|
|
Discussion
Although the judgment of an individual’s perception concerning aesthetic value is
greatly influenced by continuous observations and their concept of beauty and perfectness,
it remains unclear to what amount it is conditioned by age, gender, race, and cultural
background.[10] A structured review of the literature assessing the perfect breast by Rubano in
2019 agreed that no clear formula to create the “ideal” breast exists and therefore
appropriate discussion must happen between surgeons and patients to understand the
artistic aesthetic and its linear measurements which constitute patient's ideal breast.[11] In considering ideal breast shape, certainly patient fulfillment should be the important
touchstone and not the natural look.[12] Henceforth, these findings should illustrate the basic underlying variations of
desired breast shape (size) across demographics, redefining expectations of breast
appeal.
The size of the NAC is one of the vital characteristics in defining the attractiveness
of the breast.[10] Owing to its striking border and appealing contrast that rise at the center of the
mount, it is not only easily recognized but also rendered as the apparent feature
that makes up a beautiful breast as a whole. The accepted standard areola size has
been classically set at 38 to 45 mm.[1] In our finding, universally (43%), 46.6% of men and 53.5% of women across all ethnicities
preferred 30 mm diameter as the ideally perfect NAC (
[Fig. 2] A), which was in accordance with the previous anthropometric study done locally.[13] However, it was slightly different to Westerners, wherein the ideal size was 35
to 45 mm.[12] This is most probably due to the distinctive topographical and racial distribution
between these two opposing continents. These findings showed consistency in the eastern
part of the globe; if not East Asia, at least Malaysia where the participant demographic
comprises the majority ethnicities found in Asia (Malay, Chinese, and Indian), although
from the same nationality. This was similarly presented recently in another study
of ideal breast perception in Asia, albeit the population was only from China, Korea,
and Japan (common ancestry), with the exclusion of Malay Archipelago and Indian lineage.[14]
Fig. 2 (A) Most preferred nipple-areola complex (NAC) size in percentage among the participants;
(B) most preferred breast size in percentage among the participants.
Throughout history, women seem to accentuate the look of their breasts, with large
bust considered the supreme beauty in many cultures, which has been associated with
exceptional fertility compared with regular sizes.[10] Furthermore, the oversizing consequences are well-recognized and are among the typical
reasons for their reduction.[15] Therefore, breast size is one of the critical features affecting attractiveness.
For perfect female bust, generally, participants preferred size C and D cup (37.8%
and 38.5% respectively) (
[Fig. 2] B), with most of the men (59.6%) favoring larger size D cup and women (62.8%) opting
for C cup. Based on ethnicities, Malay and Chinese preferred C cup (28.1%), whereas
Indians preferred larger size D cup (14%). A previous local study on anthropometric
ideal breast corresponded to this result, whereby the ideal size was approximated
to the C cup.[13] Meanwhile, DD and E cup is enormous, an indication to seek reduction, hence the
lower number in proportion. Among anthropometric studies on ideal breast, the mean
breast volume for Turkish women was 407.2 mL, while among Malaysian women, the values
of the right and left breast volumes were 553.38 mL and 536.59 mL, respectively.[13]
[16] For Korean women, the mean volume was 386.0 mL for the right breast and 393.3 mL
for the left breast.[17] In studies of perception, male preferences for female breast size seem to be greatly
variable. Among the Sudanese Azande, men preferred long pendulous breasts; the Alorian
men of Alor Island in Indonesia favored large breasts; and the men of the Kenyan Massai
tribes preferred firm upright breasts.[18] Universally, 40% of men and 25% of women favored large breasts across different
cultures and ethnicities, and most studies executed on ideal breasts emphasized size,
with the finding that men from Western regions prefer medium or big breasts, while
in Malaysia, men with a low socioeconomic society considered bigger breasts to be
more attractive.[19]
[20]
[21] By comparison, plastic surgeons preferred breast size D cup, which demonstrated
universal consistency within the population.[22] In general, more men than women preferred a larger female breast across different
cultures and ethnicities, mainly Caucasians, Asians, and African-Americans, including
this study.[19]
[23]
[24]
Although NAC and breast size are among the essentials affecting aesthetics, yet the
key factor is not just an explicit size, but rather a shape and body proportions.
It is believed only breast size in proportion to the body will find attractiveness.
The authors identified some limitations in this preliminary study which prohibit it
from achieving a more substantial result. Chiefly contributing to these restrictions
is the sample size. From the technical perspective, the questionnaire can be developed
via three-dimensional (3D) photographs, with features of rotation, pan, and zoom to
enhance and accurately assess the “size” in 3D plane perspective. The use of an interactive
online questionnaire enhances user practice and is easier to operate. Authors realized
that the perception of beauty is somewhat confounded subjectively and heavily persuaded
by time, trend, and media which can be potentially altered. Nonetheless, authors feel
the quest to search for ideal attributes in aesthetic female breasts is preeminent
in this age to suit the current need, although these values might be shifted in the
near future. Therefore, with this preliminary result, researchers would have a new
idea to drive a more comprehensive study, in order to extend its confirmation, relevance,
and significance.
Conclusion
The majority of women seek perfect breast, and the aspiration for an oversized look
has finally been challenged by these findings. In this present day, people, in general,
prefer moderation in size, that is, neither too big nor too small to be the most perfect
female breast shape and which can assist a plastic surgeon in counseling patients
for breast augmentation surgery.