Breast augmentation has recently been reported to be the first or second most common surgical procedure in plastic surgery (1). Within the last 5 years, the discipline of breast augmentation has been recognized as being not just a surgical procedure but as a process that involves four subprocesses (2):

Tissue-based preoperative planning is the second of the four components of the process of breast augmentation that is essential to obtaining reproducible results in breast augmentation while at the same time minimizing the reoperation rate (2). Although preoperative planning has historically been performed subjectively by surgeons, in the last 15 years the reoperation rate at 3 years in multiple premarket approval Food and Drug Administration (FDA) studies has been 15% to 20%, reflecting the unscientific and often arbitrary approach to implant selection. Recent advances in tissue-based planning have demonstrated not only a simplified method of planning, but also one that matches implants to patient tissues and breast dimensions; it has produced superior patient outcomes. There are different “systems” for implant selection; most are not true tissue-based systems that take a set of breast measurements and then use those data directly to derive options for implant selection that “fits” that breast. Actually, very few systems can claim to be tissue-based systems based on that definition. The most recently described tissue-based planning system is the “high five” process (3). The high five process was developed over 15 years, and this third-generation system codifies the five most important decisions surgeons make during the preoperative planning phase that affect patient outcomes.

Accurate planning is not unique to breast augmentation but is relevant in all professions and results in success in areas from business ventures to sporting endeavors. Surgeons often ask, “How do I pick the implant?” “What implant gives the best results?” “What implant do patients like best?” The truth is that it is not about the implant, but rather the process, or more specifically the process of breast augmentation (2). In fact, in a recent FDA implant premarket approval application (PMA) hearing, although the devices were discussed, the next most visible concerns were about complications in patient reoperation rates.

The bottom line in selecting breast implants is that it is about “wishes versus tissues.” In other words, patients wish they looked like a actress or a model on the cover of a magazine, or want to have breast implants the same size as their friend, who may have a totally different breast/body type. However, what really matters is their tissues and to assess these objectively and to match the implant to the tissues specifically.

The concepts of tissue-based planning are well established in the plastic surgery literature. In published and peer-reviewed series as well as national presentations in the last few years, there have been more than 2,500 primary breast augmentations (4,5,6) performed with similar concepts to tissue-based preoperative planning with reoperation rates of less than 3% with 6- to 7-year follow-up, compared to the reoperation rate of 15% to 20% within 3 years in all the PMA studies in the last 15 years.

The immediate predecessor to the high five process was a tissue-based planning system developed by Tebbetts (7). This was the first tissue-based system of its kind. It prioritized the tissues of the patient as the most important factor, contrary to previous generations such as the McGhan BioDimensional system, which prioritized the desired result (i.e., desired intermammary distance, or desired breast projection) of the patient or surgeon over the tissue. The TEPID system (tissue characteristics of the envelope, parenchyma, and implant and dimensions and filler dynamics of the implant) was primarily a tool to determine tissue-based implant volume, and some aspects of the acronym were difficult for many surgeons. In the current third-generation high five process the five critical preoperative decisions that determine outcomes have been codified and put into a simple, easy-to-follow algorithm for patient assessment that can be performed in less than 5 minutes.

The five critical decisions in the high five process include the following:

The high five process has been found to be safe and simple. It leaves the control totally up to the surgeon and gets the surgeon “on base.” The process is applicable to all implant types, including regular gel, highly cohesive form-stable gel, and saline implants. It is effective and proven, and, most important, it is transferable, meaning that surgeons, residents, patient coordinators, and even patients have successfully used this system to objectively select implants appropriately for a given patient’s breast.

There are four primary measurements: