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

Incision location is based on patient preference, patient considerations of degree of surgical control, tissue trauma, and tradeoffs, and surgeon preferences and skill set.

DISCUSSION

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 implants 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. 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. 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.

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