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Current Cup Size
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Desired Cup Size
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Size Comments
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Base Width
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Nipple to Notch Distance
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Difference in Amount Breast Tissue
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Breast Tissue Difference Description
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Nipple Position Difference
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Nipple Position Asymmetry Description
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Different Sizes Left vs Right
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Left vs Right sizes comments
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Description of Breast Tissue Quality
• • •
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Ptosis Present
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Ptsosis
• • •
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Ptosis Grade and Description
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ALLERGAN Silicone Implant Size
• • •
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Infra-mammary
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Allergan Saline Implant Size
• • •
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Other Approach
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Under the Muscle
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Nipple Lift w/ Aug
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Dual Plane
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Potential Secondary Nipple Lift
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Breast Reduction Procedure
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Breast Symptoms
• • •
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Anticipated Breast Tissue Removal
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Breast Reduction Comments
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Reduction Waiver
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