High Five - Pg3
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High Five - Pg3
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Inframammary Fold Location TOP The ideal nipple-to-inframammary fold distance to mark preoperatively and set intraoperatively depends on the projected width of the postoperative breast (Fig. 1, section 4). To estimate the optimal level of the inframammary fold, the surgeon first locates the volume closest to the previously calculated net estimated implant volume. In the cell immediately beneath, the system lists a Recommended new N:IMF distance (cm) under maximal stretch. The surgeon circles the recommended number and then transfers that number to the cell in the row below labeled High Five recommended N:IMFMaxSt. Next, the surgeon transfers the preoperative N:IMFMaxSt measurement to the cell labeled Patient's Preoperative N:IMFMaxSt in the same row. If the recommended intraoperative N:IMF for the planned volume implant is greater than the patient's preoperative N:IMFMaxSt, the surgeon should consider lowering the fold to the recommended level. If the recommended N:IMFMaxSt is the same or longer than the patient's preoperative N:IMFMaxSt, no lowering of the fold is indicated. After comparing the preoperative N:IMF with the recommended N:IMF, the surgeon decides whether to lower the fold, and circles either Yes or No. If the choice is to lower the fold, the surgeon then records the appropriate number of centimeters to lower the fold in the cell below Lower the Fold. Incision Location TOP Incision location is based on patient preference, patient considerations of degree of surgical control, tissue trauma, and tradeoffs, and surgeon preferences and skill set. The surgeon records the planned incision location in the appropriate space in Figure 1, section 5. DISCUSSION TOP An accurate, efficient decision support process defines priorities and identifies a minimal number of essential decisions and provides quantifiable parameters on which to base those decisions. When prioritizing soft-tissue coverage in breast augmentation, two pinch thickness measurements are a minimum for making decisions regarding muscle coverage and location of muscle coverage. To estimate an appropriate volume for an envelope, minimum parameters include base width, skin stretch, nipple-to-inframammary fold measurement, and the contribution of the patient's existing breast parenchyma to stretched envelope fill (envelope fill equals implant plus parenchyma). Optimal volume for a breast soft-tissue envelope is the least volume that is required to either (1) achieve the desired result in a previously unstretched breast or (2) adequately fill a previously stretched envelope and ensure optimal soft-tissue coverage and minimize negative tissue effects by the implants. When forcing tissues to a desired result, surgeons and patients must carefully consider potential tissue consequences and possible uncorrectable deformities that may occur long term. Instead of forcing tissues to a desired result, the High Five process estimates a volume the tissues are likely to tolerate without selecting an implant that is wider than the patient's existing parenchyma (sacrificing coverage medially and laterally) and without adding excessive weight that can produce irreversible tissue changes. Having determined an optimal estimated volume for an individual patient's envelope, the surgeon can then select implant type and dimensions to control the distribution of that volume within the breast. For any specific volume, implant width, projection, and height can vary. Width is the most important parameter affecting volume because of its range of variability and the effect of a change in width on a change in volume. Height of an implant in vivo depends on many factors, including overlying tissue characteristics, implant fill volume relative to mandrel volume, implant filler characteristics, and implant shell-filler interactions. Because implant height is so variable in vivo in non-form stable devices and is difficult to measure accurately, implant width and projection are the most clinically significant parameters. Refinements to the system address suggestions from surgeons and residents who use the system routinely to assist with augmentation decisions. For resident education, this decision support process provides a codified, logical template with priorities and specific measurement techniques that allow residents to make decisions based on quantifiable parameters instead of stuffing test implants into bras or using other arbitrary and subjective methods. The High Five process suggests an initial estimated implant volume based on the base width of a patient's breasts. The volume this system recommends is an averaged volume for a range of implant devices that provides maximum volume without exceeding the base width of the patient's existing parenchyma. These volumes were derived from implant width-volume relationships from implant manufacturers' size chart publications for all implant types (saline and silicone) in the United States. Averaging the dimension-volume relationships provided a range of volumes for implant widths at half-centimeter increments. To make the system easier to use and memorize, the volume increments were rounded to the nearest 25-cc increment. Surgeons can base decisions of breast implant size and implant pocket location on subjective and arbitrary patient and surgeon preferences or can base decisions on quantifiable data to characterize individual patient tissue characteristics. Scientific analysis and evidence-based outcomes analysis require quantified data. Reoperation rates of 15 to 20 percent in multiple premarket application studies over the past two decades with silicone and saline implants9-11 suggest an opportunity for better decision-making processes by surgeons and patients. Reoperations for size exchange, visible rippling or wrinkling, implant malposition, implant exposure or extrusion, ptosis, and other deformities can relate directly to the consequences of decisions that the patient and the surgeon make preoperatively. Establishing quantitative criteria for optimal soft-tissue coverage, implant pocket location, and implant size can significantly affect overall reoperation rates.3-6 Comprehensive, staged patient education is essential to help patients understand and accept responsibility for the potential long-term implications of their wishes and their decisions.12 A process that prioritizes decisions, provides quantified data to assist with decisions, and defines specific criteria for soft-tissue coverage and implant volume based on individual patient tissue characteristics is an additional tool for surgeons and patients. Any system that suggests a volume range relative to the width of breast parenchyma (prioritizing soft-tissue coverage) mandates a balance between implant width, height, and projection. Volume is weight, and weight applied to breast envelope tissues over time has consequences that are obvious to anyone who has observed a D-cup breast at age 18 and the same breast at age 30 or later, and obvious to anyone who has seen the effects of pregnancy on the breast. For any base width implant, increasing implant projection requires an increase in the volume (weight) of the implant. Increased projection also can place additional pressure on overlying tissues-breast parenchyma, subcutaneous tissue, and skin. Increasing projection, therefore, has two potentially negative tissue consequences: increasing weight effects and increased pressure effects. Weight and pressure over time can cause stretch and thinning of the envelope, and focal pressure or excess pressure over time can cause atrophy of parenchyma and subcutaneous tissue. Envelope thinning and parenchymal atrophy are irreversible and may permanently preclude a patient from having optimal soft-tissue coverage, increasing risks and decreasing results of any future reoperations. Implant manufacturers currently provide surgeons and patients with the widest array of implant device dimensions in history, enabling patients and surgeons to choose a device with dimensions (size and volume) to force tissues into virtually any configuration a patient may desire. Forcing tissues to go where they have never been (and some might argue, were never intended to go) has potential short- and long-term tissue consequences, some of which are irreversible. Whether a system of implant selection is purely dimension based, volume based, or a combination of dimension and volume (e.g., the High Five process), negative tissue consequences are usually the result of excessive weight (volume), pressure (projection), or both. What is excess weight or projection depends on individual patient tissue characteristics, and surgeons must individualize clinical judgments in each case. One important question is whether patients and surgeons have an inherent right to place any volume they desire in a breast. The answer is yes, provided both are aware of and willing to accept responsibility for potential tissue consequences. A second important question is whether a process recommends volumes that satisfy patients while protecting tissues. Although this is a difficult question to answer scientifically, in published reports of 1664 cases with up to 7 years of follow-up,3-5 when integrated with staged, repetitive patient education, the volumes recommended by the system produced results that resulted in 3 percent overall reoperation rates and a reoperation rate of 0.2 percent for size exchange. In an independent review, the junior author has clinical experience with over 300 augmentations over a 6-year period using this system, producing an overall reoperation rate of 2.8 percent and a 0.4 percent reoperation rate for size exchange.6 Optimal preoperative patient education, patient decision support, and informed consent processes that document patient accountability for requests and decisions are critical. The High Five process does not replace or define patient or surgeon preferences or choices. Instead, it prioritizes decisions, provides guidelines based on quantified tissue characteristics of each individual patient, and provides an opportunity for surgeons to consider patient requests during the process and make choices outside the recommendations of the system. To ensure optimal, long-term coverage, the base width of a breast implant should not exceed the base width of the patient's parenchyma. In practice, this means that surgeons must be willing to explain to patients that narrowing the intermammary distance (cleavage gap) surgically requires placing an implant edge medial to existing parenchymal coverage, risking edge visibility, palpability, and traction rippling long term. Each of these problems is largely uncorrectable, especially if surgeons divide medial origins of the pectoralis to narrow the intermammary distance. These problems are almost totally preventable by advising patients that narrowing of the cleavage gap is more safely accomplished by pushing the breasts with a bra compared with surgically placing an implant under thin, inadequate soft-tissue coverage, and confirming the patient's acceptance of these facts in informed consent documents. In patients with extremely narrow base width breasts (body width < 10 cm) or tubular or severely constricted lower pole breasts, achieving a satisfactory aesthetic result may require an implant with a base width that exceeds the base width of the existing parenchyma. In these cases, patients and their surgeons should thoroughly discuss the potential long-term tradeoffs and tissue consequences (i.e., thinner areas of tissue, palpable or visible implant edges or shell, and visible traction rippling) and arrive at a mutually acceptable risk-benefit decision. In aesthetically appealing breasts, the wider the breast, the longer the nipple-to-inframammary fold distance. The inframammary fold is the only fixed landmark on the breast, and determining optimal inframammary fold position at the time of breast augmentation is a major factor that affects the aesthetic result. An excessively short nipple-to-inframammary fold distance relative to breast width produces a wide, boxy appearing breast with inadequate lower pole dimensions and fill. An excessively long nipple-to-inframammary fold distance relative to breast width produces a bottomed out appearance, with excessive lower pole dimensions and fill often accompanied by upward tilt nipple-areola malposition. The premise that surgeons should never lower the inframammary fold ignores the critical aesthetic relationship between breast width (determined largely by implant base width) and nipple-to-inframammary fold distance that defines optimal postoperative aesthetics. When indicated, lowering of the inframammary fold is a critically important maneuver in breast augmentation, and it is accurate and predictable when surgeons use optimal measurements and techniques. Many factors, including stretch factors that surgeons cannot control, can affect inframammary fold position long term, but surgeons need basic guidelines during operative planning to decide whether repositioning of the inframammary fold may be necessary for optimal aesthetics. The High Five guidelines for inframammary fold position are derived from preoperative and postoperative measurement data on large numbers of patients1 and can be modified by surgeons according to specific clinical situations and considerations. The High Five process is currently being used not only by surgeons but also by clinical assistants, patient educators, and by patients who wish to perform self-assessment as part of their educational process. In the senior author's (Tebbetts) practice, many out-of-town patients who express an interest receive a special, condensed version of the High Five Clinical Evaluation Form with numbered instructions by e-mail. Interestingly, their self-assessments have been extremely accurate, and the majority of these patients fully understand the concepts of the system. CONCLUSIONS TOP The refined and simplified TEPID system, evolved into a decision support process, the High Five process, defines five critical decisions in primary breast augmentation and allows surgeons and patients to quantify individual patient tissue characteristics and to base decisions about soft-tissue coverage (implant pocket location) and implant volume (size, weight, and dimensions) on objective parameters instead of subjective, arbitrary parameters. The High Five process is a comprehensive yet simple and efficient decision and management model for primary breast augmentation. The process addresses five critical priorities and decisions in breast augmentation: optimal soft-tissue coverage, implant size (volume/weight), implant dimensions, location of the inframammary fold, and incision location. Although providing volume recommendations relative to the base width, stretch characteristics, and nipple-to-inframammary fold distance, the system also allows surgeons to add or subtract volume based on specific patient requests, considering possible long-term tissue tradeoffs and consequences. In conjunction with staged, repetitive patient education and decision-making algorithms, the TEPID system has helped minimize reoperations for size exchange (0.4 percent versus 8.7 percent in premarket application studies) and reduce overall reoperation rates (3 percent versus 17 percent in premarket application studies).3-8 For any process to be effective, surgeons must use it. The demands of clinical practice mandate that this process is efficient and comprehensively addresses essential clinical priorities. A comprehensive decision support process must address a wide range of implant types and prioritize the patient's tissues long term. The High Five process prioritizes five decision categories, involves only five measurements and five decisions, and requires less than 5 minutes to perform all measurements and complete clinical planning to optimize patient outcomes. REFERENCES TOP 1. Tebbetts, J. B. Breast implant selection based on patient tissue characteristics and dynamics: The TEPID approach. Plast. Reconstr. Surg. 190:1396, 2002. 2. Tebbetts, J. B. Dimensional Augmentation Mammaplasty Using the BioDimensional System. Santa Barbara, Calif.: McGhan Medical Corporation, 1994. Pp. 1-90. 3. Tebbetts, J. B. Patient acceptance of adequately filled breast implants. Plast. Reconstr. Surg. 106:139, 2000. [Fulltext Link] [CrossRef] [Context Link] 4. Tebbetts, J. B. Dual plane (DP) breast augmentation: Optimizing implant-soft tissue relationships in a wide range of breast types. Plast. Reconstr. Surg. 107: 1255, 2001. [Fulltext Link] [CrossRef] [Context Link] 5. Tebbetts, J. B. Achieving a predictable 24 hour return to normal activities after breast augmentation: Part II. Patient preparation, refined surgical techniques and instrumentation. Plast. Reconstr. Surg. 109: 293, 2002. [Fulltext Link] [CrossRef] [Context Link] 6. Adams, W. P., Jr., Rios, J. L., and Smith, S. D. Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: 6 year prospective clinical study. Plast. Reconstr. Surg. (in press). 7. Mentor Corporation. Saline-Filled Breast Implant Surgery: Making an Informed Decision. Santa Barbara, Calif.: Mentor Corporation, 2000. Pp. 11-19. 8. McGhan Medical Corporation. Saline-Filled Breast Implant Surgery: Making an Informed Decision. Santa Barbara, Calif.: McGhan Medical Corporation, 2000. Pp. 10-18. 9. Mentor Corporation. Saline-Filled Breast Implant Surgery: Making an Informed Decision. Santa Barbara, Calif.: Mentor Corporation, 2000. Pp. 11-19. 10. McGhan Medical Corporation. Saline-Filled Breast Implant Surgery: Making an Informed Decision. Santa Barbara, Calif.: McGhan Medical Corporation, 2000. Pp. 11-19. 11. Whalen, T. V., et al. Transcript of General and Plastic Surgery Devices Panel of the FDA Medical Devices Advisory Committee, October 14-15, 2003. Available at: http://www.fda.gov/ohrms/dockets/ac/03/transcripts/3989T1.htm . 12. Tebbetts, J. B.An approach that integrates patient education and informed consent in breast augmentation. Plast. Reconstr. Surg. 110: 971, 2002. [Fulltext Link] [CrossRef] [Context Link]
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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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