Key Insights From a Decade of Breast Augmentation: Our 5 Critical Decisions in Breast Implant Selection

Abstract

Background:

Breast augmentation continues to rank among the most commonly performed procedures. A crucial factor in achieving successful outcomes lies in a methodical implant-selection system, a principle underscored by Tebbetts and Adams in their TEPID and High Five systems. We have revisited several factors during years of experience.

Methods:

Thorough preoperative consultations play a pivotal role, involving discussions on the patient’s motivation for breast augmentation and their medical history. Subsequently, medical photographs are taken, and 5 critical breast measurements are recorded: sternal notch–nipple distance, base width of the breast, soft-tissue coverage of the implant, optimal implant selection based on volume and dimensions, and calculation of the neo-inframammary fold using the Pythagorean theorem. Our system goes beyond traditional approaches by offering patients the chance to preview the postoperative result through both bra sizers and 3-dimensional simulation. Shared decision-making is another integral aspect of our methodology, providing patients with a voice in the medical decision-making process.

Results:

During the period from 2009 to 2019, the senior author conducted primary breast augmentations on 716 patients, with follow-ups extending up to 3 years. Notably, 1.5% (11 patients) required reoperation, and only 0.03% (2 patients) underwent reoperation specifically for implant size exchange.

Conclusions:

Our system’s strength lies in its reliance on straightforward tissue-based measurements and a commitment to incorporating patient preferences through interactive decision-making. We aim to contribute to the professional development of fellow plastic surgeons and residents by sharing our 5 critical decisions, confident in their potential value for enhancing their practice.

Takeaways

Question: What are essential factors during implant selection, building upon existing principles, while addressing the demands of the modern patient?

Findings: This approach incorporates key characteristics, implant dynamics, and the importance of precise incision placement and neo-inframammary fold location. Additionally, our system emphasizes patient engagement through visualization tools, ensuring a more collaborative decision-making process between the patient and surgeon. Excellent results were achieved in 716 patients over 10 years.

Meaning: Our system excels in simple tissue-based measurements, emphasizing patient preferences through interactive decision-making. We hope to contribute to the education of colleagues by sharing our method.

INTRODUCTION

Breast augmentation remains one of the most frequently performed aesthetic surgical procedures in the United States, as reported by the American Society of Plastic Surgeons¹ in 2022. The inframammary approach stands out as the most frequently used technique. Currently, mainly smooth and microtextured breast implants are used due to a significant correlation between breast implant texturing and breast implant–associated analplastic large cell lymphoma.²

In the present era of digitalization and abundant information, most patients who come for breast augmentation are well prepared and informed, have predefined preferences, and wish to participate in decision-making regarding their choice of breast implant sizes. Numerous preoperative implant size selection systems have been described.³ The key to successful breast augmentation lies in a logical system of tissue-based measurements and decisions, as already pointed out by Adams and Mckee,³ Tebbetts and Adams,⁴ and Tebbetts.⁵ Their TEPID system included tissue characteristics (T) of the envelope (E), the parenchyma (P), and the implant (I), and the dynamics (D) of implant and filler distribution affecting the previously listed soft tissues. In their groundbreaking article, “Five critical decisions in breast augmentation using five measurements in 5 minutes,” Tebbetts and Adams⁴ showed their High Five system as an effective and swift systematic method of thinking and subsequent decision-making for choosing the right breast implants. However, in the current era of well-prepared patients and shared decision-making, we believe that a 5-minute process is not in line with what patients expect nowadays. Moreover, Tebbetts’ system lacks the determination of the exact place for the incision and neo-inframammary fold (IMF) location.

Therefore, we propose a revisited systematic methodology that builds upon existing principles while addressing the demands of the modern patient. This approach incorporates key characteristics, implant dynamics, and the importance of precise incision placement and neo-IMF location. Additionally, our system emphasizes patient engagement through visualization tools, ensuring a more collaborative decision-making process between the patient and surgeon.

Patients’ Medical History and Wishes

Every patient is different and so is the rationale behind their desire for breast augmentation. A good patient–physician relationship starts by providing a listening ear. Moreover, this may also provide the plastic surgeon with often subtle but critical information regarding their wishes for the final cosmesis. In our experience, satisfactory results can only be achieved through thorough and honest consultation. Obtaining the patient’s medical history and insight on lifestyle (athletics, diet, medication/substance use, etc.) is essential, as this may influence expectations, recovery, and outcomes.

Medical Photographs

Subsequently, we proceed by taking preoperative pictures of the breast in frontal, oblique, and lateral views. This is important to accurately document patient features and measurements, as well as helps the surgeon to build a portfolio of cases; this is especially of importance in an era of increasing digitalization and social media through which patients often embark on their journey in the search of a “top” plastic surgeon.

Measurement of the 5 Essential Key Points of the Breast

Breast and tissue characteristics differ per patient. These characteristics in combination with the patient’s desires will influence the final implant choice. Five key measurements should be obtained that ultimately guide toward choosing the best-fitting implant that fulfils the patient’s wishes:

1. Measure the sternal notch–nipple distance in a standing position. Ideally, this should be around 21 cm and helps to decide whether a breast augmentation is sufficient to create a pleasing breast shape and form. The thoracic shape also plays a key role, as it influences this distance. The degree of breast ptosis is also noted to assess whether concomitant procedures are necessary, such as a simultaneous or 2-stage augmentation mastopexy. Stretched and impaired skin following aging or weight loss often requires additional lifting, as filling alone will not suffice.

2. The base width of the breast combined with breast tissue thickness and quality by the pinch test determines the width of the breast implant. The base of the breast (and the IMF) is a key anatomical landmark of the breast that greatly influences the overall breast shape. A breast augmented with an implant too small for its anatomical base width may appear ptotic. On the contrary, an oversized implant base may cause fitting problems or give an aesthetically unpleasing axillary or lateral volume increase. During this stage, cleavage/sternal gap correction may be considered.

3. Soft-tissue coverage of the implant: The thickness and quality of the breast tissue determine the position of the implant, either subfascial/subglandular or dual-plane. The pinch test guides the surgeon’s choice for placement. A pinch test of 2 cm or more will suffice for subfascial/subglandular placement, whereas less than 2 cm requires additional implant coverage achieved with dual-plane placement. We believe that the dual-plane technique is a perfect technique to prevent the visibility of the breast implant in the upper pole, but it should be avoided in case of sufficient tissue coverage to avoid unnecessary pain and the chance of visible animation.

4. Selection of the right implant is done with regard to volume and shape (based on points 2 and 3) and taking into account the patient’s wish of breast shape and volume. When seeking the right implant size, it is important to obtain a realistic view of the potential end result. To get an accurate understanding of the patient’s desired volume, we always conduct a fitting session with sizers in a fitting bra in front of a large mirror. The previously obtained measurements can be used as guidance. Bra sizers provide a firsthand experience of what the final result could be when dressed. Furthermore, we enhance the bra sizer fitting experience by capturing photographs during the session, allowing the patient to conveniently review and reconsider their choices in the comfort of their own home. Based on this fitting session and the measurements obtained in points 2 and 3, the ideal implant will be chosen from the implant catalog. The selected theoretically perfect implant will then be applied in a 3-dimensional simulation (Crisalix; see Figs. 1A-C). A picture is worth a thousand words, and the same applies to choosing the perfect breast implant. In our experience, 3-dimensional simulation software is a very useful tool providing the preoperative consultation with a new dimension. It gives the surgeon the opportunity to show the patient which implant would fit them best according to their body type and obtained measurements. Adjustments can be made, and simulations can be tailored to the patient’s wishes, such as changes in volume or projection following the fitting session. Implant shape is an important variable to take into account in this phase of decision-making: for example, round-shaped breast implants accentuate the upper pole, whereas anatomical breast implants accentuate the base and mostly have a more neutral slope.⁶ For patients with more widely spaced breasts, lipofilling of the superomedial breast can be combined with implant augmentation to improve their cleavage. However, the major adjusting variable is the projection of the implant. The implant width should be kept nearly identical, as this provides the breast with the necessary structure on which the projection is based. Caution should be exercised with broad implant widths to avoid iatrogenic synmastia due to the “tent effect.” Crisalix (Crisalix S.A., Lausanne, Switzerland) offers a broad selection of applicable breast implants. It is important to inform patients that the final aesthetic outcome may vary from the preoperative virtual breast augmentation representation.

5. Calculation of the new IMF location: The incision location and IMF reconstruction are based on implant choice and the Pythagorean theorem (α² + β² = γ²) (Fig. 2). The radius (α), or half of the implant diameter, and the projection (β) of the implant can be found easily in the manufacturer’s guide for the implant. Subsequently, the hypotenuse (γ) can be calculated with the previous values. As mentioned earlier, the IMF is an important anatomical structure of the breast. The scar should be placed correctly in the new IMF with the fullness of the lower pole providing concealment. A perfectly positioned scar is an extra factor that adds significantly to the final cosmesis. A poorly positioned scar can compromise the final aesthetic outcome, even if all other preferences have been fulfilled. The senior author has previously published how the Pythagorean theorem can be used to determine the location of the incision and thus scar.⁷ Some patients may require correction of the IMF location. This is especially important in revision breast augmentation, for example, after bottoming out.

Fig. 1.

The 3-dimensional simulation using Crisalix of the expected final result in our 33-year-old patient with Nagor (GC Aesthetics, Dublin, Ireland) IMP-HR 390cc round breast implants. A, Frontal. B and C, Oblique left and right, respectively.

Fig. 2.

The Pythagorean theorem (α² + β² = γ²). The radius (α), or half of the implant diameter, and the projection (β) of the implant, with the hypotenuse (γ) can be calculated with the previous values. Yellow marks the location for the incision and neo-IMF.

Shared Decision-making

In the past years, we have noticed a positive trend in patients who have performed thorough research on information available on breast augmentation and implants. Recent media attention on breast implant controversies is a presumable contributor. Often, patients will read professional articles, shaping their preferences accordingly. We have experienced that this significantly elevates the level of apprehension from both sides and strengthens the relationship with the patient. Shared decision-making has been advocated as the perfect model for medical consultations and suits a modern patient–physician relationship. Four key characteristics of shared decision-making have been identified: (1) involvement of at least a physician and a patient; (2) both involved parties share information; (3) both parties work toward a consensus regarding the preferred treatment; and (4) an agreement is reached on the preferred treatment strategy.⁸ Patients should be adequately informed on the pros and cons of surgical technique: approach, and thus, scar localization (axillary, inframammary, periareolar, and umbilical); placement (pre-/subpectoral); and implant characteristics such as shape (anatomical/round), size, and texturing (smooth, textured, polyurethane).

Operating Technique

Preoperative surgical planning is shown in Figure 3. First, the midline is marked, followed by the current anatomical border of the IMF. Subsequently, the new IMF and incision location are drawn in accordance with the calculations of the Pythagorean theorem (red). The medial-caudal part of the breast is undermined in the subglandular space (yellow). (See Video 1 [online], which displays how the medial-caudal part of the breast is undermined in the subglandular space.)

Fig. 3.

Preoperative markings and operative technique. The new IMF and incision location are drawn in accordance with the calculations of the Pythagorean theorem (red). The medial part is undermined in a subglandular fashion (yellow) and cranially in a subpectoral fashion (green), in case of dual-plane placement. The pectoralis major is released medially (blue).

Video 1. which displays how the medial-caudal part of the breast is undermined in the subglandular space.

Download video file ^{(38.8MB, mp4)}

Subsequently, an entrance is created in this space to access the subpectoral space, releasing it sufficiently to accommodate the implant’s dimensions. (See Video 2 [online], which displays how an entrance is created in the pectoralis major to access the subpectoral space, releasing it sufficiently to accommodate the implant’s dimensions.) Finally, the pectoralis major is released medially (blue) to better expand the lower pole in the subglandular space (dual plane), reducing the risk of animation deformity. (See Video 3 [online], which displays how the pectoralis major muscle is released medially after meticulous pocket dissection.)

Video 2. displays how an entrance is created in the pectoralis major to access the subpectoral space, releasing it sufficiently to accommodate the implant’s dimensions.

Download video file ^{(87.6MB, mp4)}

Video 3. displays how the pectoralis major muscle is released medially after meticulous pocket dissection.

Download video file ^{(28.1MB, mp4)}

Type 2 degree of dual-plane dissection was performed in 98% of the cases. Type 3 was used in a few cases of breast ptosis. After meticulous preparation, the exact breast pocket size can be assessed by air inflation. This is performed by lifting the breast tissue, which traps air in the pocket through negative air pressure. (See Video 4 [online], which displays how the size of the newly created breast pocket can be assessed by air inflation. This is performed by lifting the breast tissue, which traps air in the pocket through negative air pressure.) Finally, the new IMF is reconstructed after the insertion of the breast implant with 3 periosteal sutures with a thick absorbable braided suture.

Video 4. displays how the size of the newly created breast pocket can be assessed by air inflation. This is performed by lifting the breast tissue, which traps air in the pocket through negative air pressure.

Download video file ^{(12.2MB, mp4)}

From 2009 to 2019, the senior author (B.v.d.L.) performed primary breast augmentations on 716 patients at Bergman Clinics in the Netherlands, with follow-ups extending up to 3 years. The median age was 36 years (range 20–53 y). Median implant size used was 305 mL (range 140–630 mL). Breast implants by Nagor and Perle (GC Aesthetics, Dublin, Ireland) were used in this study. Round implants were used in 94% of the cases. All patients received 2 g of cefazolin preoperatively. Breast pockets were irrigated with a povidone-iodine 50% diluted with NaCl 0.9% solution. The skin around the opening was disinfected using the same solution. A supporting bra was advised for 6 weeks postoperatively. Typically, patients were discharged the same day and came for follow-up consultations after 1 week and 1 year. Notably, 11 (1.5%) patients required reoperation, and 2 (0.03%) patients underwent reoperation, specifically for implant size exchange, within the first 3 years postplacement. Nine patients underwent reoperation for capsular contracture of grade III or IV, with an average time to reoperation of 8.5 years (range 6–10 y). Additionally, 2 patients experienced implant rupture after a period of 7 and 9 years. Two patients chose to increase implant volume, one by 100 mL and the other by 135 mL, both involving round implants. See Figures 4 and 5 for preoperative and postoperative photographs after 6 months of our 33-year-old patient who underwent dual-plane breast augmentation with Nagor (GC Aesthetics) IMP-HR 390cc round breast implants.

Fig. 4.

Preoperative photographs in frontal and oblique views of our 33-year-old patient. A, Frontal. B and C, Oblique left and right, respectively.

Fig. 5.

Postoperative photographs after 6 months in our 33-year-old patient who underwent dual-plane breast augmentation with Nagor (GC Aesthetics, Dublin, Ireland) IMP-HR 390cc round breast implants. A, Frontal. B and C, Oblique left and right, respectively.

DISCUSSION

A plethora of preoperative planning systems, each with its pros and cons, have been published and described in a systematic review by Adams and Mckee.³ In 2002, Tebbetts presented their groundbreaking TEPID system for selecting the ideal breast implant volume. The revised High Five decision support process enabled plastic surgeons to gauge breast characteristics such as implant soft-tissue coverage efficiently within 5 minutes.⁴ Undoubtedly, numerous plastic surgeons have benefited from the TEPID and High Five systems for swift preoperative planning and achieving exceptional and reproducible outcomes. Over the years, we have incorporated several new but important dimensions into this system, adapting it to meet the needs and expectations of the modern patient. In this article, we describe our revised system, which has naturally evolved after years of personal experience by the senior author (B.v.d.L.) in breast augmentation.

Thorough preoperative planning is crucial to minimize reliance on sizers; mitigate the risk of unexpected intraoperative events that could prolong surgery; and consequently, reduce the complications and reoperation rates.⁹ Additionally, systematic decision-making enhances reproducibility and yields excellent results consistently. Numerous similar preoperative implant size selection systems have been published and can be categorized into systems that do not rely on measurements (surgeon artistry, sizers, etc.), dimensional systems (measurements flexible to achieve a result), and tissue-based systems (measurements largely rigid).³ The strength of our system lies in the simplicity of tissue-based measurement while simultaneously focusing on patient preferences through interactive engagement and shared decision-making. The (tissue-based) High Five system proved very successful, as the authors reported only 3% reoperations in 1664 breast augmentations with a follow-up of 7 years, with only 0.2% reoperations for implant size exchange.⁴ Until thus far, our (primarily dimensional) system yielded similar outcomes: a reoperation rate of less than 2% and only 2 cases necessitating reoperation for implant size exchange. We attribute these outcomes to a combination of expertise, procedural consistency, standardization through a preoperative planning system, and the integration of shared decision-making.

The inframammary approach is still the most versatile and popular way to perform a breast augmentation, because of better access, control with regard to pocket dissection, and less chance of bacterial contamination. However, especially with the increasing use of smooth and microtextured implants, control and reconstruction of the IMF is of utmost importance to prevent bottoming out. We have included presurgical planning to determine the exact location of the incision, new IMF, and IMF reconstruction based on the Pythagorean theorem.⁷ The Pythagorean theorem takes into account the geometric characteristics of the bottom height and projection of the implant in combination with the skin stretch of the lower pole. This is somewhat similar to the Akademikliniken method described by Hedén and the ICE (implant dimensions [I], capacity of the breast [C], and excess tissue required [E]) principle.¹⁰ We believe that the Pythagorean theorem provides the surgeon with an easier and more straightforward calculating tool compared with the High Five system and other methodologies.^4,10 This simple, yet efficient, mathematical formula only takes maximally a minute of total calculating time. We presently apply the formula across all types of implants, notwithstanding the fact that the original article specifically focused on round breast implants.⁷

We are aware that bra sizers are controversial and thus remain a topic of discussion.¹¹ Nonetheless, we offer patients the option of experiencing different breast volumes preoperatively, within the boundaries of suitable breast implants. This aligns with the approach advocated by Hidalgo and Spector,¹² though we assert that a single fitting session is adequate. Smaller breast size is a momentous motive for many women seeking breast augmentation. In our experience, bra sizers have proven to be a valuable asset, offering patients a sense of the final volume while clothed during preoperative consultation. A patient’s inclination might surpass the suggested volume within our system, making this step simultaneously serve as a means of managing expectations. It is essential to communicate with patients that the depiction serves as a visual representation, offering an approximation of the potential postoperative appearance following breast augmentation with a specific volume.

Finally, we have included shared decision-making as an important pillar in our revised system. We respectfully believe that only 5 minutes of measurements, as proposed by Tebbetts and Adams,⁴ to decide what is best for the patient does not fit in the current time of shared decision-making. Preoperative implant size selection systems should guide the surgeon and advise patients on the best-fitting implant. Surgeons may opt to neglect this advice in case this does not correlate with the patient’s desire. The right combination of preoperative planning and patient desires may result in long-term satisfactory results and fewer complications.

Our system, developed through years of clinical experience by the senior author (B.v.d.L.), is recommended specifically for planning primary inframammary breast augmentation, which could be perceived as a limitation. Revision surgery may present unforeseen challenges that could disrupt preoperative planning, although such cases are less frequent in primary breast augmentation. We also suggest that colleagues prioritize expertise, especially in complex cases such as tubular breast formation. Additionally, the use of the Pythagorean theorem to calculate the new IMF location underscores a preference for an inframammary approach. The recorded reoperation rate pertains specifically to cases within our knowledge, acknowledging the possibility that patients may have sought the expertise of other plastic surgeons or undergone revision procedures elsewhere.

CONCLUSIONS

The foundation for successful inframammary breast augmentation lies in a straightforward yet logical system. Although various excellent systems have been outlined previously and proven to be successful, this article introduces our refined preoperative planning system designed for optimal implant selection. Our system excels in simple tissue-based measurements, emphasizing patient preferences through interactive decision-making. We hope to contribute to the education of fellow plastic surgeons and residents by sharing our method and are confident in its potential value for their practice.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ETHICAL APPROVAL

The patient information in this study was collected by the authors and de-identified. The study was approved by the medical ethical committee of the University Medical Center Groningen.