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

The High Five System applies to a wide range of implant types, sizes, and dimensions. 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.

Inframammary Fold Location

The ideal nipple-to-inframammary fold distance to mark preoperatively and set intraoperatively depends on the projected width of the postoperative breast. 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.

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