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, 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. 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 patients and can be modified by surgeons according to specific clinical situations and considerations.

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