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FIVE CRITICAL DECISIONS IN BREAST AUGMENTATION PLANNING TOP Surgeons must make preoperative decisions in five critical areas when planning a breast augmentation. Each of these decisions should be based on quantifiable measurements or data. In order of priority, these decisions define: 1. Optimal soft-tissue coverage/pocket location for the implant. This determines future risks of visible traction rippling, visible or palpable implant edges, and possible risks of excessive stretch or extrusion. 2. Implant volume (weight). This determines implant effects on tissues over time, risks of excessive stretch, excessive thinning, visible or palpable implant edges, visible traction rippling, ptosis, and parenchymal atrophy. 3. Implant type, size, and dimensions. This determines control over distribution of fill within the breast; adequacy of envelope fill; and risks of excessive stretch, excessive thinning, visible or palpable implant edges, visible traction rippling, ptosis, and parenchymal atrophy. 4. Optimal location for the inframammary fold based on the width of the implant selected for augmentation. This determines the position of the breast on the chest wall, the critical aesthetic relationship between breast width and nipple-to-fold distance, and distribution of fill (especially upper pole fill). 5. Incision location. This determines degree of trauma to adjacent soft tissues, exposure of implant to endogenous bacteria in the breast tissue, surgeon visibility and control, potential injury to adjacent neurovasculature, and potential postoperative morbidity or tradeoffs. A comprehensive system for implant selection should address each of these critical decision areas and provide the surgeon with specific, quantifiable data to consider when making decisions and assessing outcomes. BACKGROUND OF THE TEPID SYSTEM TOP The TEPID system [tissue characteristics of the breast (T), the envelope (E), parenchyma (P), implant (I), and the dimensions (D) and dynamics of the implant relative to the soft tissues] for breast implant selection, based on the patient's individual tissue characteristics and breast dimensions, was published in this Journal in April of 2002.1 The system has been refined and simplified to include only five measurements that address five prioritized decisions in implant selection and operative planning for breast augmentation that surgeons can complete in 5 minutes. This process is designed to address essential parameters that affect aesthetic results, compromises, complications, and reoperation risks in breast augmentation. Additional clinical experience with the TEPID system has redefined priorities in decision making and created a simpler and more efficient process for surgeons gaining familiarity with quantitative decision making in breast augmentation-the High Five process. The TEPID system evolved from the senior author's (Tebbetts) experience with the first dimensional system (later licensed by Inamed Corporation as the BioDimensional System) for breast augmentation,2 a system that defined a patient's desired result by dimensions and then selected an implant to force tissues to the desired result. The BioDimensional System has been widely used by surgeons in the United States and internationally, but clinical experience with the system defined specific limitations that encouraged the development of the TEPID system. The first-generation BioDimensional System (1) defines implant dimensions and volume that force patient tissues to an arbitrary result defined by patient and surgeon desires instead of quantitatively characterizing the patient's tissue dimensions and characteristics, and selecting an implant to fit the requirements and limitations of the tissues; (2) incorporates no system to limit volume and weight according to patient tissue characteristics, allowing patients and surgeons to define a desired result dimensionally and select implants that may be larger or more projecting than ideal for the patient's tissues, risking potential long-term negative tissue consequences that can be irreversible; (3) does not specifically address the number one priority in breast augmentation, that is, ensuring optimal soft-tissue coverage of the implant long-term; and (4) does not address a critical third dimension, tissue stretch, which is a critical measurement to estimate volume required for optimal envelope fill. The TEPID system was designed to specifically address the limitations of the first-generation BioDimensional System by defining a paradigm shift in planning breast augmentation. Instead of forcing tissues to a desired result defined by the patient and surgeon, the TEPID system encourages patient and surgeon to prioritize the long-term welfare of the patient's tissues and ensure optimal soft-tissue coverage over the implant to minimize negative tissue consequences long term and minimize reoperation rates. The TEPID system is designed to help patient and surgeons reconcile wishes with the tissues by quantifying important tissue characteristics and helping patients reconcile their preconceived desires for a specific result with the realities of their tissues. The High Five process presented in this article further focuses and simplifies an established system of quantitative patient tissue assessment and adds a defined decision support process. CLINICAL EXPERIENCE TOP The senior author's (Tebbetts) clinical experience with the TEPID system includes more than 2000 primary breast augmentation cases. In three series reported in this Journal, with up to 7 years of follow-up of 1664 reported cases, the overall reoperation rate was 3 percent, and the reoperation rate for implant size exchange was 0.2 percent.3-5 The junior author's (Adams) clinical experience includes more than 300 augmentations with up to 6 years of follow-up using this system, with an overall reoperation rate of 2.8 percent.6 Although these rates are from a single surgeon's experience, these data provide an interesting comparison with the overall reoperation rates of 17 percent and rates for size exchange or adjustment rates of 8.7 percent from the averaged data of Mentor and McGhan submitted for their saline premarket approval studies in 2000.7,8 Additional experience by the authors and input from other colleagues and residents further codified and refined the TEPID system to a comprehensive decision support process that specifically addresses five critical decisions in breast augmentation. For efficiency, the High Five process does not include any parameters that are not essential to one of these decisions, and the process enables surgeons to perform all measurements and make all implant selection and operative planning decisions in 5 minutes or less. MEASUREMENTS, IMPLANT SELECTION, AND OPERATIVE PLANNING TOP With the patient sitting and the High Five Clinical Evaluation and Operative Planning Form (Fig. 1) resting in the patient's lap, the surgeon performs five measurements, records the measurements, and makes five prioritized decisions within 5 minutes or less. During the process, the surgeon can discuss the measurements, decisions, implications, and tradeoffs with the patient.
A copy of the High Five Clinical Evaluation and Operative Planning Form is downloadable from the Journal's Web site at www.plasreconsurg.org , along with a video file including measurement techniques and the entire decision-making process. Details and illustrations of the required measurements and estimates are included in the previous system1 and are abbreviated in this report. Soft-Tissue Coverage and Pocket Selection TOP The surgeon performs the first two measurements and records the measurements on the evaluation sheet (Fig. 1, section 1): STPTUP: soft-tissue pinch thickness of the upper pole (skin and subcutaneous tissue superior to the breast parenchyma (Fig. 2, above).
STPTIMF: soft-tissue pinch thickness at the inframammary fold (Fig. 2, below). Implant pocket selection is based on quantified soft-tissue coverage to ensure optimal long-term coverage over the implant. If soft-tissue pinch thickness of the upper pole is less than 2.0 cm, the surgeon chooses a dual-plane or partial retropectoral pocket location to ensure optimal soft-tissue coverage. Adding fascial coverage (retromammary, subfascial pocket) of less than 1 mm thickness is inconsequential long term when pectoralis muscle coverage is available and when dual-plane techniques enable surgeons to minimize tradeoffs of traditional retropectoral placement. When selecting a dual-plane or partial retropectoral pocket location to optimize coverage, the surgeon never divides origins of the pectoralis major from the sternal notch to the sternal junction with the inframammary fold to ensure optimal coverage in this critical area, regardless of a patient's desired intermammary distance. If soft-tissue pinch thickness at the inframammary fold is less than 0.5 cm, the surgeon preserves intact pectoralis muscle origins along the inframammary fold for additional coverage, creating a partial retropectoral pocket (compared with a dual-plane pocket in which the surgeon divides pectoralis origins along the fold). Considering the quantified measurements of soft-tissue thickness, the surgeon chooses either dual-plane 1, 2, 3, partial retropectoral, or retromammary pocket location, and circles the choice on the form. Implant Volume TOP Next, the surgeon measures and records the following parameters (Fig. 1, section 2): Base width (BW) of the existing breast parenchyma, a linear measurement (Fig. 3).
Anterior pull skin stretch (APSS), a measurement of maximal anterior skin stretch by manual traction comfortably tolerated by an awake patient (Fig. 4).
Nipple-to-inframammary fold distance (N:IMFMaxSt), measured under maximal stretch (Figs. 5 and 6).
Parenchyma to stretched envelope fill (PCSEF), an estimate of the contribution of the patient's existing breast. To estimate the parenchyma to stretched envelope fill, the surgeon pulls the periareolar skin maximally anteriorly (anterior pull skin stretch), then cups the hand or envisions the envelope stretched this same amount over the entire breast and estimates the amount of fill as a percentage that the patient's existing parenchyma will provide to the maximally stretched envelope. The surgeon then locates the base width that corresponds with the patient's base width in the row to the right. In the cell immediately beneath, the surgeon circles the initial estimated desired implant volume for that base width breast and transfers this number to the blank space at the far right of the row. This volume represents an estimated desired implant volume based on the breast base width. These volumes were derived from data described in the initial TEPID report1 and are adjustable by the surgeon, depending on other parameters, including patient wishes. Next, the surgeon adjusts the estimated starting volume, depending on skin stretch. If anterior pull skin stretch is less than 2 cm (very tight envelope), the surgeon subtracts 30 cc (or another increment of the surgeon's preference) from the estimated starting volume. If anterior pull skin stretch is greater than 3 cm, the surgeon adds 30 cc, and if anterior pull skin stretch is greater than 4 cm, the surgeon adds 60 cc to the starting volume, recording the appropriate addition or subtraction in the cell at the far right of the APSS row. If the nipple-to-inframammary fold distance is greater than 9.5 cm when measured under maximal stretch, the surgeon adds 30 cc (or another increment of the surgeon's preference) to the starting volume to provide adequate additional fill volume for a larger lower envelope. If applicable, the surgeon records this additional volume in the far right cell of the N:IMFmax stretch row. The parenchyma fill estimate is necessary to adjust volume for patients whose skin envelopes are tighter (anterior pull skin stretch < 2 cm) and already filled with parenchyma (parenchyma fill > 80 percent), or for patients with very lax skin envelopes (anterior pull skin stretch > 3 cm) who have very little breast parenchyma (< 20 percent). If parenchyma fill is greater than 80 percent (already full envelope), the surgeon subtracts 30 cc from the initial estimated volume, and if parenchyma fill is less than 20 percent (empty envelope), the surgeon adds 30 cc and records applicable additions or subtractions in the cell to the far right of the PCSEF row. If the patient or surgeon desires a greater or lesser volume than the system recommends, the surgeon can add or subtract an additional volume increment and record it in the space provided in the far right cell of the Patient Request row. The High Five System does not replace patient or surgeon preferences or choices. The system provides guidelines based on quantified tissue characteristics of each individual patient. By adding or subtracting increments described above from the initial estimated volume, the surgeon derives a net estimated volume that is appropriate for the patient's quantified tissue characteristics and records the appropriate number in the cell at the far right of the Net Estimated Volume row. Implant Type and Dimensions TOP The High Five System applies to a wide range of implant types, sizes, and dimensions (Fig. 1, section 3). Having derived a net estimated implant volume based on quantified tissue parameters, the surgeon can then consult size and dimension charts for any type of implant, and select implant dimensions (width, height, projection) that the surgeon feels are most appropriate. The surgeon records the implant volume, the base width of the implant selected, the base width of the patient's existing parenchyma (measured previously), and implant projection. For optimal long-term coverage, the base width of the implant selected should not exceed the base width of the patient's existing parenchyma, except in cases of tubular breasts, severely constricted lower pole breasts, or breasts with a base width less than 10.5 cm. Implant projection is an important dimension that may affect distribution of fill and tissue consequences postoperatively and is included only for postoperative reference. Surgeons should consider potential irreversible parenchymal atrophy effects when selecting highly projecting implants. |
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For further questions or to schedule a consultation call 214-965-9885 or email Dr. Adams. Dallas plastic surgeon offers plastic surgery procedures - forehead lift, browlift, breast augmentation using saline breast implants, silicone breast implants, cohesive gel breast implants, Gummy-bear breast implants, liposuction, rhinoplasty and more to Dallas, Ft. Worth, Austin, Houston and surrounding areas.
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