FIVE CRITICAL DECISIONS IN BREAST AUGMENTATION PLANNING

Surgeons must make preoperative decisions in five critical areas when planning a breast augmentation. Each of these decisions should be based on quantifiable measurements or data. In order of priority, these decisions define:

1. Optimal soft-tissue coverage/pocket location for the implant. This determines future risks of visible traction rippling, visible or palpable implant edges, and possible risks of excessive stretch or extrusion.

2. Implant volume (weight). This determines implant effects on tissues over time, risks of excessive stretch, excessive thinning, visible or palpable implant edges, visible traction rippling, ptosis, and parenchymal atrophy.

3. Implant type, size, and dimensions. This determines control over distribution of fill within the breast; adequacy of envelope fill; and risks of excessive stretch, excessive thinning, visible or palpable implant edges, visible traction rippling, ptosis, and parenchymal atrophy.

4. Optimal location for the inframammary fold based on the width of the implant selected for augmentation. This determines the position of the breast on the chest wall, the critical aesthetic relationship between breast width and nipple-to-fold distance, and distribution of fill (especially upper pole fill).

5. Incision location. This determines degree of trauma to adjacent soft tissues, exposure of implant to endogenous bacteria in the breast tissue, surgeon visibility and control, potential injury to adjacent neurovasculature, and potential postoperative morbidity or tradeoffs.

A comprehensive system for implant selection should address each of these critical decision areas and provide the surgeon with specific, quantifiable data to consider when making decisions and assessing outcomes.

BACKGROUND OF THE TEPID SYSTEM

The TEPID system [tissue characteristics of the breast (T), the envelope (E), parenchyma (P), implant (I), and the dimensions (D) and dynamics of the implant relative to the soft tissues] for breast implant selection, based on the patient's individual tissue characteristics and breast dimensions, was published in this Journal in April of 2002.1 The system has been refined and simplified to include only five measurements that address five prioritized decisions in implant selection and operative planning for breast augmentation that surgeons can complete in 5 minutes. This process is designed to address essential parameters that affect aesthetic results, compromises, complications, and reoperation risks in breast augmentation. Additional clinical experience with the TEPID system has redefined priorities in decision making and created a simpler and more efficient process for surgeons gaining familiarity with quantitative decision making in breast augmentation-the High Five process.

The TEPID system evolved from the senior author's (Tebbetts) experience with the first dimensional system (later licensed by Allergan/Inamed/McGhan Corporation as the BioDimensional System) for breast augmentation,2 a system that defined a patient's desired result by dimensions and then selected an implant to force tissues to the desired result. The BioDimensional System has been widely used by surgeons in the United States and internationally, but clinical experience with the system defined specific limitations that encouraged the development of the TEPID system.

The first-generation BioDimensional System (1) defines implant dimensions and volume that force patient tissues to an arbitrary result defined by patient and surgeon desires instead of quantitatively characterizing the patient's tissue dimensions and characteristics, and selecting an implant to fit the requirements and limitations of the tissues; (2) incorporates no system to limit volume and weight according to patient tissue characteristics, allowing patients and surgeons to define a desired result dimensionally and select implants that may be larger or more projecting than ideal for the patient's tissues, risking potential long-term negative tissue consequences that can be irreversible; (3) does not specifically address the number one priority in breast augmentation, that is, ensuring optimal soft-tissue coverage of the implant long-term; and (4) does not address a critical third dimension, tissue stretch, which is a critical measurement to estimate volume required for optimal envelope fill.

The TEPID system was designed to specifically address the limitations of the first-generation BioDimensional System by defining a paradigm shift in planning breast augmentation. Instead of forcing tissues to a desired result defined by the patient and surgeon, the TEPID system encourages patient and surgeon to prioritize the long-term welfare of the patient's tissues and ensure optimal soft-tissue coverage over the implant to minimize negative tissue consequences long term and minimize reoperation rates. The TEPID system is designed to help patient and surgeons reconcile wishes with the tissues by quantifying important tissue characteristics and helping patients reconcile their preconceived desires for a specific result with the realities of their tissues. The High Five process presented in this article further focuses and simplifies an established system of quantitative patient tissue assessment and adds a defined decision support process.

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