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

Next, the surgeon measures and records the following parameters:

Base width (BW) of the existing breast parenchyma, a linear measurement.

Measure the base width of the breast mound as a linear measurement from the visible medial border of the breast mound to the visible lateral border of the breast mound in front view.

Anterior pull skin stretch (APSS), a measurement of maximal anterior skin stretch by manual traction comfortably tolerated by an awake patient.

(Left) Measure anterior pull skin stretch by grasping the skin of the areola and pulling it maximally anteriorly (while holding a caliper in the same hand), and then mark that point with a fingernail on the opposite hand. (Right) To complete the measurement of anterior pull skin stretch, release the skin and caliper measure from the point marked by the fingernail back to the resting plane of the areola.

Nipple-to-inframammary fold distance (N:IMFMaxSt), measured under maximal stretch.

To measure nipple-to-inframammary fold distance under maximal stretch, first place dots at the exact inframammary fold crease near the 6-o'clock position and just medial to the midpoint of the nipple. Place the tip of a flexible tape measure exactly at the dot beside the nipple, lift maximally to place the lower pole skin under maximal stretch, and measure to the dot at the inframammary fold.

(Above, left and center) To estimate parenchymal contribution to stretched envelope fill, first measure the anterior pull skin stretch by the techniques described previously. (Above, right) Place a pen or envision a line from the point of maximal stretch tapering into the upper pole. (Below, left) Cup the hand or envision a curved line that parallels the lower pole profile of the breast at a distance equal to anterior pull skin stretch. (Below, right) The white dotted line simulates the maximally stretched envelope for this patient based on the patient's anterior pull skin stretch. Envision this line, and estimate the percentage of this stretched envelope that is filled by the patient's existing parenchyma. This concept is easy to demonstrate to the patient using the pen and cupped hand.

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