The Process of Breast Augmentation with Special Focus on ... · Breast implants can be either round or anatomi-cally shaped. Of note, round implants are used in 95% of primary breast

The Process of BreastAugmentation with

KEYWORDS

� Breast augmentation � Patient education � Tissue-based planning � Patient selection� Implant selection

KEY POINTS

� Breast augmentation is not simply a surgical procedure but a process of 4 steps: (1) comprehensivepatient education and informed consent, (2) tissue-based preoperative planning, (3) refined surgicaltechnique with rapid recovery, and (4) detailed postoperative education.

� The nonsurgical steps, patient education and tissue-based planning, are essential to optimizingpostoperative outcomes and reducing reoperation rates.

� The surgeon and the patient must assume a mutual responsibility that the implant has beenselected based on breast dimensions and soft tissue limitations.

� Dedicated education, comprehensive patient/surgeon consultation, analytical documentation, and3-dimensional imaging should be coupled with tissue-based planning to optimize results.

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INTRODUCTION

The critical analysis of breast augmentation and itsassociated complications has driven our surgicalpractice to redefine our approach. We have scruti-nized factors that influence patient outcomes andhave acknowledged key characteristics thatshape the successes of this common surgical pro-cedure. This assessment has redirected breastaugmentation from a surgical procedure into asurgical process.1 Four key components havebeen outlined in this surgical approach:

1. Comprehensive patient education and infor-med consent

a Department of Plastic Surgery, The University of Texas S120, University Park, TX 75205, USA; b Plastic Surgery,c Plastic Surgery, New York Presbyterian Hospital, 156 W* Corresponding author.E-mail address: [email protected]

Clin Plastic Surg 42 (2015) 413–426http://dx.doi.org/10.1016/j.cps.2015.06.0010094-1298/15/$ – see front matter � 2015 Elsevier Inc. All

2. Tissue-based preoperative planning3. Refined surgical technique with rapid recovery4. Detailed postoperative education

These 4 steps to breast augmentation havebeen integrated into our surgical practice andhave improved the patient experience, the reoper-ation rate, the postoperative outcome, and overallpatient/surgeon satisfaction.1 Even though these 4steps can exist independently, the integration of all4 steps in a patient’s surgical experience worksynergistically to optimize esthetic outcomes.Our refined process was developed in part frompublished concepts2 and other plastic surgicalpractices have adopted this same protocol with

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equally positive conclusions; thus, this breastaugmentation 4-step process is both transferableand reproducible. This article focuses on the first2 steps of this comprehensive 4-step process ofbreast augmentation.

PATIENT EDUCATION AND INFORMEDCONSENTTeam Approach to Education

The first step in the process of breast augmenta-tion is the educational component; this step isthe most critical aspect of the process and isfrequently neglected by plastic surgeons. Thisapproach solidifies a surgeon/patient partnershipbefore surgical intervention, because this processrequires not only the surgeon but also the entirestaff of the clinical practice to be an integral partic-ipant in the subprocess of patient education. Thus,the surgical team has a responsibility to introducethe patient to the philosophy of the surgical prac-tice. Instructional material and promotional multi-media may serve as an adjunct to the standardsof the practice and influence patient education.The patient and practice must create a partner-

ship for implant selection and postoperative care.Together, they develop a mutual understandingthat the implant will not only be selected based onpatient preference, but also must incorporatebreast dimensions and tissue characteristics. Thepatient must understand the limitations of herbreast envelope and the implications of implant se-lectionbasedonbreast topography. Together, theywill reviewpatient images andphysical attributes todelineate breast asymmetry and anatomic bound-aries that impact implant selection. Furthermore,the practice patient educator and surgeon have aresponsibility to discuss various implant options(eg, silicone vs saline, anatomic vs round, texturedvs smooth) and how the selected implant is influ-enced by patient characteristics. This partnershipin implant selection and postoperative care hasbeen proven to enhance patient satisfaction andoverall esthetic outcomes.1 Recently, in our prac-tice, 3-dimensional imaging has significantly revo-lutionized this partnership by allowing patients tovisualize how an implant “fits their breasts,” aswell as potential differences between shaped andround implants.The informed consent process is integrated into

the educational process3; the risks should be dis-cussed including, but not limited to, bleeding,infection, capsular contracture, implant malposi-tion, rippling, and need for reoperation. A preoper-ative understanding of the complication profile willempower the patient to assume responsibilityfor the final decision. A new development that

deserves attention during the patient consultationis the association of anaplastic large cell lymphoma(ALCL) and breast augmentation. Current evidencesuggests the risk of developing ALCL is 0.1% to0.3% per 100,000; in relative terms, a patient isapproximately 2 times more likely to be struck byan asteroid than to develop ALCL.4 Patients typi-cally present with a delayed seroma after 1 year.The clinical course is indolent, and effective treat-ment includes removal of the implant andcapsulectomy. Adjuvant therapy is rarely recom-mended. Fewer than 50 cases have been reportedin the medical literature, but patients should beaware of this recent finding. Initial studies havesuggested a correlation of ALCL with textured im-plants and/or certain bacteria, but more investiga-tions need to be undertaken for any definitiveconclusions.4

Determine Patient Knowledge/Patient Desires

The process of patient education and informedconsent requires a multimodality approach. Moreoften than not, patients have a misconstruedperception of breast augmentation based on previ-ous experiences or multimedia influence. Thesurgeon and practice have a responsibility todismantle any misconceived notions and educatepatients on the relationship of breast tissue andimplant selection. Our practice requires each pa-tient to complete documents before an educationconsultation by our patient education specialist(Fig. 1). This consultation, in person or over thephone, typically lasts 45 to 60 minutes and dis-cusses concepts, issues, and limitations relatedto the process of breast augmentation. Thisconsultation is able to decontaminate anymisinfor-mation and convey the importance of tissue-basedplanning and implant selection. For example, thecoordinator can dispel the inaccurate associationof cup size and breast augmentation; most womenwear inappropriate bras for their cup size and cupsize is nonstandardized within the industry. At thistime, the patient educator also can determineif the patient desires a “natural-look” or an“augmented-look” for her breast augmentation;this mentality will directly impact the rest of theconsultation and implant selection. Again, 3-dimensional imaging can be an integral componentof this discussion; patients can project various“looks” and can even overlay a bra or camisoleon these simulations to optimize visualization.Thus, patients and surgeons can select the implantbased on the breast envelope and implant charac-teristics rather than improper misconceptions.The education coordinator initially performs the

consultation with the patient, typically done in

Patient Concerns

Additional Questions for Dr. Adams

Have you had any type of Plastic Surgery before?�Are you happy with your results?� My role in your care� Our commitment to patient education�What we’ll talk about today�Have you read the information we provided you?� Clinical evaluation sheet medical history and patient preferences� Brief history of augmentation� Alternatives versus a single approach� Do implants cause disease? The research and sources� Breast implants and breast cancer� Breast implants and mammography

All implants interfere with mammograms�Breast implant technology� Constantly changing alternatives- current

alternatives� Limitations of implants- no implant is without

tradeoffs� Summarizing the alternatives� Incision alternatives- inframammary, axillary,

periareolar� Implant pocket locations- retromammary,

retropectoral, dual plane, totally submuscular� Current implant choices (all saline)- Smooth

round, textured round, textured shaped or anatomic-types and manufacturers� Fitting the procedure and implant to your tissues

to minimize long-term risks and compromises� Determining the best size� If you could just pick a size, what would it be?�Which is more important, size or problems long-

term?� Common misconceptions� How implant size affects your tissues- now and

later� Bra cup sizing-we can't guarantee cup size� Balancing your breast with your figure�Measuring your breast, understanding your tissues� Concentrating on shape, fill, dimensions� Photos and planning the operation� The operation- what’s it like� Day surgery routine� The facility and facility personnel� Anesthesia

Safety of anesthesia, misconceptions, risksLocal versus general anesthesiaOur anesthesia personnel

� During surgery�What will occur, expected time frame

� After surgery� Waking in recovery, then to stepdown with

caregiver� Detailed instructions will be given to you

Tells you and your caregiver what to expect and do

What we do simplifies your instructions� Recovery and activity� Importance of resuming normal activity�What we do and what we need you to do� No bandages, bras, straps, drains or special

� Risks of augmentation� This is a totally elective operation with risks

and uncontrollable factors� Bleeding� Infection� Sensation compromise� Capsular contracture� Unsatisfactory aesthetic results or scarring� Interference with cancer detection� Complications may require additional surgery,

longer recovery, additional costs� Reviewed risks on consent forms & documents

� Capsular contracture and breast firmness�What is it?� How a capsule forms� Controlling the capsule� How often does it occur?� Correcting the hard breast

� Factors that the surgeon cannot predict or control

� Capsular contracture�Different degrees, if severe, requires reoperation�Surgeon alone makes final decisions re:

reoperation�All costs are patient's responsibility, no

insurance� Tissue stretch problems- increase with implant

sizeo Stretch allowing implant shift downward or

outward� Stretch allowing implant rotation� Traction rippling

� Your request for a different size implant after surgery� All costs for any surgery relating to factors the surgeon cannot predict or control are the patient's responsibility (surgeon fees, facility fees, anesthesia, lab, time off work)- includes capsular contracture, stretch deformities, implant size changes.� Importance of communicating with us

We want to do what you wantYou must be honest with us at all timesThe surgeon cannot read your mind�What you can expect from Dr. Adams

Type of care. Written materials. Photos. The operation. Your care.� Dr. Adams’ Qualifications

Surgical training, board certification, professional affiliations, scientific publications, other.� Patient has read all information material provided (Yes/No) _____Pt. Initial.� Discussed any significant other's involvement, gave patient copy of Will There Be Anyone Else Involved.�Written information provided patient was discussed in detail with patient, answered patient's questions to patient's satisfaction.� All informed consent documents discussed in detail with patient, answered patient's questions.

_______Pt. Initial _______Pt. Educator Initial

Fig. 1. Our breast augmentation patient educator consultation checklist.

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person or on the phone, as a separate consult thatprecedes the surgeon consultation. During thesurgeon consultation, the surgeon can objectivelyreview the breast dimensions, confirm the pa-tient’s goals, and formulate a surgical plan. In thepatient-surgeon interaction, asymmetries areidentified and directly addressed using an image

analysis sheet (Fig. 2). Patients must have realisticexpectations on intermammary distance, cleav-age, implant characteristics, and implant palpa-bility. By dispelling any misconceived notions,the surgeon and the patient can synergisticallyselect the appropriate implant based on individual-ized tissue. Additionally, with joint preoperative

Patient: «Person_First_Name» «Person_Last_Name»

Date: ____________

� L/R breast larger- breasts will never match!!!� L/R nipple-areola higher on chest- will not be totally corrected� L/R fold beneath breast higher on chest- will not be totally corrected� Nipple position on the breast mounds is different on the two sides and cannot be totally corrected� Gap between breasts can only be narrowed somewhat- a gap of at least _____cm. will likely remain� Chest wall asymmetries exist that cannot be corrected and will affect breast shape� The position of the entire breast on the chest wall will not change. If one fold beneath the breast is lower than the other, it will also be lower after your augmentation.� The basic shape and configuration of the breasts will be similar to their current appearance and not change drastically, but will be larger� Thinner tissue inferior and lateral can result in implant palpability

� Other: ___________________________________________________________

� Other: ___________________________________________________________

� Other: ___________________________________________________________

� Other: ___________________________________________________________

Patient Please Initial below to document your understanding and acceptance of the above.

_____ Dr. Adams has reviewed my patient images with me in detail. I have seen, understand, and accept each of the factors listed above that will not change or may be only partially improved following my augmentation. I totally understand and accept that my breasts or components of my breasts will never match on the two sides, and that perfection is not an option, only improvement in the size of my breasts.Fig. 2. Our breast augmentation patient image analysis checklist.

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planning and implant selection, patients willaccept their postoperative results and rarelypresent for size-exchange procedures. Approxi-mately 20% of patients in our practice may ques-tion their size postoperatively, but they arereminded of the preoperative planning with theassociated photographs, which usually reaffirmsimplant size selection and patient satisfaction.5

IMPLANT CHARACTERISTICS/SURGICALAPPROACHShaped Versus Round

Breast implants can be either round or anatomi-cally shaped. Of note, round implants are used in

95% of primary breast augmentations in theUnited States.4 Within both subsets, there are awide variety of widths, heights, and projections.Anatomic implants may even have more variabilitybecause of their naturally asymmetric shape. Plas-tic surgeons should vary implant selection to opti-mally “best fit” a breast envelope. However,surgeons may use only one implant style becauseof their training or comfort. Our practice believessome situations dictate a certain implant basedon patient preference or breast anatomy.5 Super-seding all of these sentiments is the concept thatthe best patient for an anatomic implant is the pa-tient who “wants it.” Indications for both round

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implants and anatomic implants are outlined asfollows:

Round implants1. Desired augmented look2. Good soft tissue coverage/good basic breast

shape3. Revision surgery (change of implants, capsular

contraction, implant rupture, rotation)4. Recurrent implant rotation/concerned about

rotation

Anatomic implants1. Desiring a natural look with minimal or no breast

tissue2. Shapeless breast or breast with poor soft tissue

coverage3. Constricted lower pole or tuberous breast

deformity4. Simple or complex asymmetry5. Ptosis or lower pole laxity (poor tissue may limit

placement)

Smooth Versus Textured

Textured devices were initially created to mimicthe external shell of polyurethane implants; theseimplants had a coarse porous exterior with verylow capsular contracture rates.6 Recent Level 1trials have not demonstrated lower capsularcontracture rates in textured implants in the sub-pectoral pocket; however, some clinical studieshave suggested reduced capsular contracturerates using textured implants in the subglandularspace.6 Most likely, the low capsular contracturerates seen in polyurethane implants were relatedto a biochemical reaction and not the texturing ofthe device.6 Of note, smooth implants are currentlyused in approximately 90% of patients receivingprimary breast augmentation in the United States.4

Our practice uses texturing only for anatomicimplants.

Saline Versus Silicone

A patient’s anatomy or personal preference maydictate saline or silicone filler; however, the fillershave distinct properties that should be discussedduring the initial patient consultation. Advantagesof saline implants include smaller incisions from aremote location, less required monitoring, anddecreased costs. Disadvantages of saline implantsinclude increased risk of wrinkling and palpability,less natural touch, more tissue effects over time,and spontaneous deflation. Advantages of siliconeimplants include less wrinkling and palpability, norisk of sudden deflation, and a more natural touch.Disadvantages of silicone implants include MRI

monitoring, “silent rupture,” increased costs, anda slightly longer incision. The implant choice inour practice is typically selected by patient prefer-ences and breast anatomy.

Pocket Plane

Implants can be placed in the subpectoral, sub-glandular, subfascial, or dual-planepocket. Advan-tages of the subpectoral position include improvedupper pole contour, decreased incidence ofcapsular contracture, and better breast tissue visu-alization during mammography. Disadvantagesinclude increased discomfort from submusculardissection and potential rare occurrence of implantdistortion by pectoralis contraction, although aproper dual-plane pocket negates all thesedisadvantages.

Subglandular placement of implants may beappealingbecauseofmisconceptionsofdecreasedpostoperative pain and ease of dissection; how-ever, the disadvantages of subglandular positioningtypically outweigh these positives, including poorsuperior pole esthetics and rippling, increasedcapsular contracture, and difficult mammographyimaging.

Subfascial placement has been suggested byvarious investigators to offer the same protectionas submuscular placement against capsularcontracture with less postoperative pain; however,the pectoralis fascia layer is typically thin andrequires a tedious dissection. Our practice hasfound minimal clinical indications for subfascialplacement.

The dual-plane technique places the implantpartially subglandular and submuscularly. Incre-mental and planned release of the submuscularfibers at the muscle-gland interface allows the sur-geon to vary the muscle coverage of the implantleading to optimal implant–breast parenchyma dy-namics.7,8 Dual-plane position eliminates virtuallyall of the disadvantages of the traditional submus-cular approach while maintaining the benefits ofmuscle coverage.9 All implants placed in our prac-tice are dual-plane with the exception of true bodybuilders.

Incision Selection

Popular available incisions for breast augmenta-tions include inframammary, peri-areolar, axillary,and peri-umbilical. Certain patient anatomy orimplant choice may suggest an incisionalapproach; however, often the chosen incision ispatient/surgeon preference. The inframammaryapproach continues to be the most popular ac-cess for breast augmentation, as it provides thebest control. This approach offers visualization of

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the subpectoral plane without violating the breastparenchyma. Indications for this incision includesmall areolar diameter, large form-stabled im-plants, glandular ptosis, and large-volume im-plants (>400 mL). The real challenge/key point ofthe inframammary approach is placement of theincision at the postoperative inframammary crease(the new inframammary fold [IMF] incision). If theplacement is miscalculated and the inframammarycrease is repositioned intraoperatively, the scarwill not be in the optimal location and poor quality.Furthermore, a malpositioned IMF would alter thepostoperative nipple-to-IMF distance and inher-ently distort overall breast esthetics. The infra-mammary approach has evolved as the preferredsurgical access of our practice; this incision is pre-dictable and reproducible when implant-specifictissue-based principles are followed and providesthe most control. We place the calculated postop-erative fold starting 1 cmmedial to the areola, thenextending a length laterally that will accommodatethe size of the implant (typically 4–5 cm).The peri-areolar incision hemi-circumnavigates

the areola, usually hidden with an inconspicuousscar at the pigment of the areola and native breastskin; however, recent studies have shown anincrease in bacterial load, and subsequently,increased capsular contracture with this inci-sion.10–12 Thus, we typically avoid this accesschoice in our practice.Axillary access for breast augmentation is an

intriguing approach because many surgeons mar-ket this access as scarless. Indications for axillarybreast augmentation include small areola diameterand small silicone implants or saline implants. Thepatient also must have appropriate breast anat-omy: adequate breast tissue, normal body habitus,and ideal shape. This incisional approach can beeither blunt dissection or endoscopic assisted. Ofnote, blunt dissection is technically easier but re-quires experience, and the endoscopic approachnecessitates complex technical equipment. Bothaxillary techniques have an increased risk of supe-rior implantmalposition because of the poor visual-ization of the inframammary crease. Furthermore,this procedure may be more painful, and revisionalsurgery normally requires anadditional remote inci-sion. Surgeons must avoid the axillary fat duringthis dissection to prevent lymphatic trauma andassociated sequelae. Some science has demon-strated a higher capsular contracture rate with thetrans-axillary incision as well,4,5 although someproponents of the incision have documentedsimilar rates.13

The peri-umbilical approach (trans-umbilicalbreast augmentation) has been discussed in theliterature for saline devices. This approach

requires an extensive blunt dissection in the sub-scarpal plane to access the subpectoral pocketand is typically reserved only for surgeon prefer-ence.4 The approach has many drawbacks anddoes not execute breast augmentation at the high-est level.During the education and surgeon consult, pa-

tients who desire various incisions are presentedthese data points, and in the past 5 years, allhave requested the new IMF incision.

Limitations Patients Should Understand

There are certain patient anatomic variations thatmay influence implant selection and deservementioning. For example, plastic surgeons andpatients must recognize chest wall morphologies,which can affect the orientation of the breasts,and thus, the positioning of the implants. A roundchest wall lateralizes the breasts; and alternatively,a rectangular chest wall medializes the breasts.Patients are counseled that the position andmorphology of the breast on the chest wall cannotbe altered with breast augmentation. Furthermore,hemithorax asymmetry or scoliosis may requiredifferent implants despite equivalent breast vol-umes to recreate symmetric chest topographies.4

A separate unique patient population is thepostpartum breast augmentations. After preg-nancy, the breast tissue atrophies with poor skinelasticity. This skin/soft tissue transformationmay accentuate implant visualization and migra-tion. Silicone implants with conservative volumesmay decrease postoperative rippling and bottom-ing out. Furthermore, these patients may havenipple hypertrophy and nipple/breast ptosis. Con-current nipple correction or mastopexy mayaugment the overall cosmesis.4

PREOPERATIVE ASSESSMENT/CONSULT KEYPOINTSPatient History

Psychosocial elements may impact the surgicalcourse; for example, the patient and surgeonmust discuss the motivations behind surgery.Does the patient hope to achieve a “natural” or“obvious” breast augmentation? We generallyassimilate all of this information in the educationportion of the consult.

Physical Examination/Measurements KeyPoints

Basic measurements are needed to assess tissuecoverage before implant selection, includingbreast base width, skin stretch, and nipple-to-IMF distance on stretch. The combination of these

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breast measurements and breast type are essen-tial for implant-specific tissue-based planning. Inbreast augmentation surgery, neither the artist(no measurements) nor the engineer (only mea-surements) is ideal, but our group has proventhat scientific measurements create surgicalboundaries for an artist to optimally function.14

Breast base widthThe breast base width (BBW) is the actual width ofthe pocket in which the implant will be placed. TheBBW is inherently smaller than the actual width ofthe breast. The BBW is the linear measurementacross the widest transverse portion of breast(usually at the nipple) from the medial border ofthe breast mound to the lateral border of the breastmound (Fig. 3).

Skin stretchThe skin stretch (SS) is measured by grasping theskin of the medial areola and pulling the breastmaximally anteriorly. The SS distance correlatesto the anterior-posterior excursion measured witha caliper (Fig. 4).

Nipple-inframammary fold on stretchThe nipple-inframammary (N:IMF) fold measure-ment is obtained by using flexible tape from themidpoint of the nipple under maximal stretch tothe IMF (Fig. 5).

Breast type (implant-specific planning)The breast type has evolved from the High-5 Sys-tem to measure the contribution of the patient’sexisting parenchyma for implant-specific tissue-based planning. We have determined 5 breast

Fig. 3. The BBW measurement.

types and these are subdivided based on enve-lope quality and N:IMF on stretch (Fig. 6).

Breast Type I (very tight) SS <1.5 cmBreast Type II (tight) SS 1.5–2 cmBreast Type III (average) SS 2–3 cmBreast Type IV (loose) SS 3–4 cm with N:IMF<9 cm

Breast Type V (very loose) SS 3–4 cm withN:IMF >9 cm

Fig. 7 represents the integration of BBW, SS,N:IMF, and breast type to create a blueprint forimplant selection for implant-specific tissue-basedplanning.

Photography

An instrumental part of the breast examinationand patient education is patient photography.Together, the surgeon and patient can identifyany asymmetries; in addition, this discussion al-lows the surgeon to reiterate that postoperativebreasts will not be identical. Furthermore, by usingphotographs, the surgeon can outline importantconcepts, including likelihood of implant palpa-bility, rationale for implant pocket dissection andincision choice, the expectations of cleavage andIMF, and the ideal implant. A useful adjunct tothis discussion is a “breast-augmentation imageanalysis form” that guides the surgeon throughthe necessary points1 (see Fig. 2).

Recently, 3-dimensional imaging has becomean integral part of our consultation and patient ed-ucation.15 The various viewpoints from a 3-dimen-sional model exponentially surpass the informationfrom a 2-dimensional photograph; thus, the pa-tient and surgeon have visual data to augmenttissue-based implant selection. Furthermore,simulated 3-dimensional images allow the patientto see a “natural” versus “augmented” look andcan thus make an informed decision for implantselection.

IMPLANT SELECTION: TISSUE-BASEDCLINICAL ANALYSIS AND PLANNING

Selecting the appropriate implant for breastaugmentation remains a challenge for many plas-tic surgeons. Patients typically discuss magazinephotographs, cup sizes, and friends’ experienceswhen suggesting implants for their respective sur-gery. However, these subjective anecdotes havelittle value in selecting the proper implant forparticular breast morphology. Recent premarketapproval studies have documented elevated reop-eration rates after breast augmentation from 15%to 24% in 6 years. With recent scientific studies,

Fig. 4. The SS measurement.

Fig. 5. The N:IMF measurement on stretch.

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we now understand tissue-based planning con-cepts that can help lower reoperation rates foraugmentation.1,9

Bra/Sizers Limitations

Some surgeons argue that volume is the mostimportant variable in implant selection and sug-gest using sizers to select an implant. Preoperativesizing consists of placing sample implants in a brato preview a range of possible results. Typically,the surgeon reviews the height, weight, and bodyhabitus of the patient and then offers a size rangeof implants. Of note, patients are informed that thesizing bra may add 30 mL to each breast. Also, if apatient desires a saline implant, the selectedimplant should be 25 mL less than its siliconecounterpart to allow for intraoperative overfillingand lower incidence of rippling. Based on this eval-uation, a patient then selects 2 implants within25 mL and the surgeon has the liberty to selectthe ideal implant based on intraoperative implantsizing and the breast mound. We have found thein-office bra sizer stuffing introduces moreunknown variables into implant selection, makingit more confusing to patients and actuallymisleading them in many cases.

Fig. 6. The 5 breast subtypes based on envelope qual-ity and N:IMF distance on stretch.

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Even though this process shares ownership andhas been proven to minimize size requestchanges,4 this process has some deficiencies.There have been no studies that have comparedthe accuracy of preoperative breast sizing andpostoperative breast volume and shape. This pro-cess is not influenced by the objective boundariesof the breast and is a very subjective experience.Furthermore, this process creates preoperativeuncertainty and empowers the surgeon insteadof the patient to select the final implant. If the sur-geon and patient together choose the idealimplant based on the tissue envelope preopera-tively, the patient knows the exact implant thatwill be placed in the operating room and has jointownership of the implant decision. Furthermore,this process of intraoperative sizers includesincreased operative time, which exposes the pa-tient to increased capsular contracture, infection

risk, and unwanted effects of general anesthesia(eg, nausea, stiffness). Despite the efforts toinclude patients in the implant process, the “sizerstuffing methodology” excludes patients from thefinal implant decision and lacks tissue-based pre-operative planning.4

High-5 System

Our practice has abandoned the subjective limita-tions of sizing and uses the tissue-based High-5system for implant selection and operative plan-ning. By adopting these tenets, our practice hasreduced our overall reoperation rate to 2.8% incomparison with the national reoperation rates.14

The basics of the High-5 process allow the sur-geon to make 5 critical decisions for optimaloutcomes:

1. Pocket plane2. Implant size3. Implant type4. IMF position5. Incision

This process is outlined in detail in the 2006article, “Five critical decisions in breast augmenta-tion using five measurements in 5 minutes: thehigh five decision support process.”9 However,since its publication, we have made the followingadvances and simplifications to the 5 steps:

1. As previously discussed, our practice uses adual-plane pocket for all patients with theexception of true body builders.

2. The measurements of BBW and SS determineoptimal fill volume. If the patient is a breasttype 1 or 2, the optimal fill volume is reducedfurther (60 mL and 30mL, respectively). Any ad-justments to the optimal fill based on the patientdesires are made. Breast type provides asimpler construct to correlate envelope qualityand tissue-based implant selection. Once thefinal optimal fill is known, 3-dimensional imag-ing using the desired implant at that optimalfill is performed with the patient.

3. The new inframammary fold incision and idealpostoperative nipple-to-fold distance is extrap-olated from the High-5 chart based on theselected implant volume. If the recommendednipple-to-fold distance is greater than the pre-operative nipple-to-fold distance, the surgeonshould consider altering the fold to the sug-gested level. A general yet effective formula isa 300-mL implant requires a nipple-to-IMFdistance of 8 cm; for every 10-mL volumetricchange, the IMF position should adjustby 0.1 cm.

Fig. 7. Integration of BBW, SS, N:IMF distance, and breast type to create a blueprint for implant selection forimplant-specific tissue-based planning. (Activas, Inc, Parsippany, NJ.)

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4. As previously discussed, our practice uses anIMF approach for all patients. This approachprovides optimal control with minimal tissuetrauma and reduced exposure to implant con-taminants, and passes the “family test”; ie,what incision would we recommend andperform on a family member?

Failure to follow tissue-based planning and nat-ural boundaries of the breast can lead to an unnat-ural appearance as well as soft tissue distortionwith inherent postoperative complications.5

Fig. 8 outlines our process for clinical evaluationand patient measurements to execute tissue-based implant selection.

Three-Dimensional Analyses

Even though 3-dimensional imaging has beenreferenced previously, the concept must be reiter-ated, as this technology has become an increas-ingly powerful educational instrument for boththe surgeon and patient in the implant decision-making process. Three-dimensional imaging, un-like its historic 2-dimensional counterpart, allowsthe patient not only to see the breast from variousangles but also to simulate postoperative resultswith the insertion of an implant. Once the surgeonand patient have applied tissue-based preopera-tive planning to select an implant, the two canvisualize the implant in the 3-dimensional model.

–

Fig. 8. Our intraoperative process for clinical evaluation and patient measurements to execute tissue-basedimplant selection.

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With this postoperative 3-dimensional simulation,the surgeon and patient can confirm expectationsbased on a scientifically proven technology ormake appropriate adjustments in the patient’sown picture based on volume and shape to affirmthe ideal implant.15 Previous investigators,including our clinical practice, have verified the

accuracy of the preoperative simulation and post-operative images for patient consultation. Fig. 9demonstrates an example of a 24-year-old womanwho had preoperative breast imaging, preopera-tive simulation, and postoperative imaging usingAllergan (Irvine, CA, USA) Style 15 to 265-mLround implants. Of note, surgeons must caution

Fig. 9. A 24-year-old woman who had preoperative breast imaging, preoperative simulation, and postoperativeimaging using Allergan Style 15 to 265-mL round implants.

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Fig. 10. A preoperative surgical simulation of a 24-year-old woman with an anatomic implant, Allergan FM 410 to205 mL, and with a round implant, Sientra MP 230 mL.

Editorial Comments by Bradley P. Bengtson, MD

A great deal is owed to Dr Bill Adams in gettingplastic surgeons to think about the surgical pro-cedures that we are performing as a “Process”verses just an event or surgical procedure.The breast augmentation Process may bebroken down into four main process categories.Although all are critical, as Dr Adams and col-leagues point out, the Patient education,Patient selection and Implant selection are byfar and away the most significant. Properpatient evaluation and education using TissueBase Planning principles and the applicationof these measurements into the patient assess-ment is essential in obtaining objective, consis-tent outcomes and minimizing adverse events,complications and breast revision surgery.

Process of Breast Augmentation 425

patients that 3-dimensional imaging is only asimulation and by no means guarantees postoper-ative results. This is no different from rhinoplasty3-dimensional imaging, which has been used suc-cessfully for many years. Despite this limitation,3-dimensionalimaging enhances the communica-tion between surgeon and patient and allows thepatient to choose an implant based on an actualimage of her body. In addition, with the resurgenceof anatomic silicone implants in the US market,3-dimensional imaging may serve as an adjunctto educating patients in different volume and sur-face characteristics. This technology has beenparticularly effective in demonstrating differencesbetween a round versus shaped outcome for agiven patient. Fig. 10 represents a preoperativesurgical simulation of a 24-year-old woman withan anatomic implant, Allergan FM 410 to 205 mL,and with a round implant, Sientra (Santa Barbara,CA, USA) MP 230 mL.

SUMMARY

Our practice has adopted the philosophy thatbreast augmentation is not simply a surgical pro-cedure but a process of 4 comprehensive steps.The nonsurgical steps, patient education andtissue-based planning, have been detailed earlierin this article and are essential to optimizing post-operative outcomes and reducing reoperationrates. The surgeon and the patient must assume

a mutual responsibility that the implant has beenselected based on breast dimensions. Further-more, they must have a shared understanding ofpreoperative breast asymmetry and soft tissuelimitations. State-of-the-art advances includededicated education, comprehensive patient/sur-geon consultation, surgical forms and analyticalsheets, and patient 3-dimensional imagingcoupled with tissue-based planning. This breastaugmentation process has been transferable toother practices with the same successes, and inthe end, with the global adaptation of thisapproach, the winner is the patient.

Adams Jr & Small426

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