64 Breast Augmentation

Rafael A. Couto, David Sieber, and William P. Adams Jr.

Abstract

Breast augmentation is not an isolated surgical procedure, but a true process consisting of four steps: (1) patient education and informed consent; (2) tissue-based planning; (3) refined surgical technique/fast-track 24-hour recovery; and (4) defined postoperative care regimen. Following these steps is key to practicing breast augmentation at the highest level, since it optimizes patient outcomes and satisfaction. Details of the process of breast augmentation are discussed and illustrated.

Breast augmentation – dual plane – High Five Process – tissue-based planning – 14-point plan

64 Breast Augmentation

Key Points

Breast augmentation outcomes are optimized using the process of breast augmentation including: (1) patient education and informed consent, (2) tissue-based planning, (3) refined surgical technique/fast-track 24-hour recovery, and (4) defined postoperative care regimen (Fig. 64.1).
We advocate performing dual-plane breast augmentation in all patients, except body builders.
The surgical 14-point plan effectively decreases surgical site infection, capsular contracture, and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

64.1 Preoperative Steps

64.1.1 Patient Education and Informed Consent

This step is critical to an optimal outcome. The surgical team educates the patient about the concepts and goals of the procedure.
The aim is to create a partnership between the patient and the surgical team for implant selection and postoperative care.

**Fig. 64.1** The four key steps for a successful breast augmentation are: (1) patient education and informed consent; (2) tissue-based planning; (3) refine surgical technique; and (4) clear postoperative care regimen. (Reproduced with permission from Adams WP Jr. ed. Breast Augmentation Video Atlas. 2nd ed. New York, NY: Thieme; 2019:2.)

64.1.2 Tissue-Based Planning

The High Five Process is used to determine preoperatively: Pocket plane, implant size/type, inframammary fold (IMF) position, and incision (Fig. 64.2).
The soft tissue pinch thickness of the upper and lower poles of the breast is measured (Fig. 64.3a).
The breast width measurement correlates with the subpectoral implant pocket. It is a linear measurement at the level of the nipple that extends from the medial border to lateral border of the breast (Fig. 64.3b).
The breast skin stretch is measured by grasping the skin medial to the nipple and pulling anteriorly (Fig. 64.3c).
The nipple to IMF (N:IMF) distance is measured from the midpoint of the nipple under maximal stretch to the IMF (Fig. 64.3d).
Three-dimensional imaging is a comprehensive consultation tool. It provides an efficient visual patient education of asymmetries of breast and chest wall, and the final scientifically accurate (98%) visual simulation of the postoperative result.

**Fig. 64.2** The High Five Process clinical evaluation form. (Reproduced with permission from Adams WP Jr. ed. Breast Augmentation Video Atlas. 2nd ed. New York, NY: Thieme; 2019:26.)

**Fig. 64.3** **(a–d)** The High Five Process measurements: (a) superior pole pinch skin thickness; (b) breast width; (c) anterior skin stretch; and (d) nipple to inframammary fold distance. (Reproduced with permission from Adams WP Jr. ed. Breast Augmentation Video Atlas. 2nd ed. New York, NY: Thieme; 2019:23–25.)

64.1.3 Breast Markings (Fig. 64.4)

The patient’s midline and IMF are marked.
The new IMF position is determined based on the established High Five relationships that correlate N:IMF position based on optimal fill volume of the given breast . A simple mnemonic is: the new IMF level can be determined by using the following method: 300 mL implant requires a N:IMF distance of 8.0 cm; for every 10 mL of volumetric change, the N:IMF distance should be adjusted by 0.1 cm. All measurements are always on maximum stretch.
The incision is marked at the new IMF. The medial extent of the incision is marked on a vertical meridian 1 cm medial to the nipple and it is then extended laterally for 4.5 cm.
Mark the height and width of the pocket dissection, which are based on the implant dimensions.