Five Critical Decisions in Breast Augmentation Using Five Measurements in 5 Minutes: The High Five Decision Support Process

[PREOPERATIVE PLANNING: REPRINTED ARTICLE: COSMETIC]

Tebbetts, John B. M.D.; Adams, William P. M.D.

Dallas, Texas

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center.

[Reprinted from Plast. Reconstr. Surg. 116(7): 2005, 2005.7rsqb;

Received for publication December 13, 2004; revised October 6, 2005.

John B. Tebbetts, M.D.; 2801 Lemmon Avenue West, Suite 300; Dallas, Texas 75204-2356; jbt@plastic-surgery.com

Please go to the online version of the Journal at www.PRSJournal.com to see the online streaming video associated with this article.

Background: Surgeons' decisions impact patient outcomes and implant effects on tissues over time. Tissue assessment systems that provide quantitative, objective data enable objective rather than subjective decisions. First-generation dimensional systems for breast augmentation defined a desired result dimensionally and recommended an implant to force tissues to the desired result. A second-generation system, the TEPID system, defines measurements to match the implant to the patient's tissue characteristics, instead of forcing tissues to a desired result. This study defines a third-generation decision support process that prioritizes five critical decisions, identifies five key measurements, and completes all preoperative assessment and operative planning decisions in breast augmentation in 5 minutes or less.

Methods: Key decision parameters and data from more than 2300 primary augmentations planned using the TEPID system were analyzed to define the five most critical decisions that affect reoperation rates and risks of uncorrectable deformities and to define a decision support process using five critical measurements.

Results: In 1664 cases with up to 7 years of follow-up, the overall reoperation rate was 3 percent, and the reoperation rate for implant size exchange was 0.2 percent. 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.

Conclusion: The High Five decision support process prioritizes five critical decisions in breast augmentation and enables surgeons to address all preoperative assessment and operative planning decisions in breast augmentation in 5 minutes or less.

When planning and performing primary breast augmentation, surgeons consider important alternatives and variables that determine short- and long-term results and the patient's risk of future tradeoffs, complications, and reoperations. Preoperative decision making is equally important compared with any aspect of surgical technique, because preoperative decisions determine the adequacy of soft-tissue coverage over the implant for the patient's lifetime, determine the weight and pressure that the implant device will exert on the tissues over time, and determine the position of the breast on the chest wall.

Identifying critical variables and decisions that affect outcomes and codifying those parameters into a simple, efficient, and reliable system provides surgeons with a framework for preoperative assessment and operative planning. Although more than 50 tissue and surgeon variables occur in every augmentation,1 any clinically practical and adoptable decision process must focus on the few critical decisions and parameters that most affect outcomes.

A quantifiable approach to tissue assessment, using measurements in lieu of subjective visual assessment, provides surgeons with quantifiable data on which to base decisions.

How a surgeon uses these data-decision priority, sequence, and algorithm-determines outcomes, tradeoffs, and reoperation risks. Previous dimensional systems for breast augmentation define a desired result and suggest methods to force tissues to that result.2 The previously published TEPID system1 incorporates quantitative tissue assessment, but instead of forcing tissues to a desired result, prioritizes soft-tissue coverage over the implant in the short and long term. The next logical step was to provide surgeons with a simple and efficient decision support process that addresses the five most critical decisions in breast augmentation, using only five measurements, with the entire assessment and planning process requiring 5 minutes or less-the High Five Process.

By integrating quantitative preoperative tissue assessment with a systematic approach to five critical decisions in breast augmentation, surgeons have an opportunity to improve outcomes, reduce reoperation rates, and improve practice efficiency. This article integrates a stepwise approach to five critical decisions in breast augmentation with a refined and simplified version of an established tissue assessment system for augmentation. The High Five decision support process adds a decision and management component to an established system for quantitative tissue assessment.

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